THIS CHAPTER DISCUSSES
•
Systematic feedback and the Partners for Change Outcome Management System (PCOMS)
•
PCOMS as a way to truly privilege clients, include them as full partners in decision-making and operationalize social justice and a pluralistic approach
The Partners for Change Outcome Management System: Duncan & Reese, 2015Barry Duncan
Despite overall psychotherapy efficacy (Lambert, 2013), many clients do not benefit (Reese, Duncan, Bohanske, Owen, & Minami, 2014), dropouts are a problem (Swift & Greenberg, 2012), and therapists vary significantly in success rates (Baldwin & Imel, 2013), are poor judges of negative outcomes (Chapman et al., 2012), and grossly overestimate their effectiveness (Walfish, McAlister, O'Donnell, & Lambert, 2012). Systematic client feedback offers one solution (Duncan, 2014). Several feedback systems have emerged (Castonguay, Barkham, Lutz, & McAleavey, 2013), but only two have randomized clinical trial support and are included in the Substance Abuse and Mental Health Administration’s National Registry of Evidence based Programs and Practices: The Outcome Questionnaire-45.2 System (Lambert, 2010) and the Partners for Change Outcome Management System (PCOMS; Duncan, 2012). This article presents the current status of the Partners for Change Outcome Management System, the psychometrics of the PCOMS measures, its empirical support, and its clinical and training applications. Future directions and implications of PCOMS research, training, and practice are detailed. Finally, we propose that systematic feedback offers a way, via large scale data collection, to re-prioritize what matters to psychotherapy outcome, reclaim our empirically validated core values and identity, and change the conversation from a medical model dominated discourse to a more scientific, relational perspective.
This study examined the effects of using client feedback, known as the Partners for Change Outcome Management System (PCOMS), with couples undergoing psychotherapy. 46 heterosexual couples were randomly assigned to either a treatment as usual (TAU) condition or to a feedback condition where therapists received feedback on client progress and the therapeutic alliance at each session via the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). It was hypothesized that couples receiving feedback would have better outcomes, improve more quickly, and be more likely to meet the criteria for clinically significant change. Results from this study aimed to replicate previous research finding client feedback beneficial for couples therapy.
The original validation of the CORS for kids and the ORS for adolescents. Allowed the benefits of client based outcome feedback to expand to youth and family and paved the way to the current RCT with kids in the schools.
PCOMS as an Alternative to Psychiatric Diagnosis (Duncan, Sparks, & Timimi, 2...Barry Duncan
Part of an incredible series about diagnostic alternatives by the Journal of Humanistic Psychology edited by Sarah Kamens, Brent Dean Robbins, & Elizabeth Flanagan
Slone, N. C., Reese, R. J., Mathews-Duvall, S., & Kodet, J. (2015). Evaluating the Efficacy of client feedback in group psychotherapy. Group Dynamics: Theory, Research, and Practice, 19, 122-136. doi:10.1037/gdn0000026
PCOMS: A Viable Quality Improvement Strategy for Public Behavioral HealthBarry Duncan
This is the latest from the research team of the Heart and Soul of Change Project, published in the Journal of Consulting and Clinical Psychology. This study demonstrated that PCOMS is not only a viable quality improvement strategy but also that services to the poor and disenfranchised provided in a public behavioral setting, contrary to earlier research, can be as effective as those delivered in randomized clinical trials.
This document summarizes a study that analyzed written responses from clients who had completed couple therapy. The study explored how clients experienced therapy through their responses to open-ended questions about therapy at a 6-month follow-up. The responses were analyzed thematically and compared between clients whose therapists did or did not use systematic feedback. Most clients found personable, active therapists who maintained neutrality to be helpful. Some expressed dissatisfaction with lack of structure or challenge from therapists. Lack of flexibility in scheduling was also problematic. Clients who used feedback generally found it very helpful.
The first quasiexperiemental study of the ORS/SRS in a telephonic EAP company. Doubled outcomes and improved retension. Set the stage for the RCTs that followed
The Partners for Change Outcome Management System: Duncan & Reese, 2015Barry Duncan
Despite overall psychotherapy efficacy (Lambert, 2013), many clients do not benefit (Reese, Duncan, Bohanske, Owen, & Minami, 2014), dropouts are a problem (Swift & Greenberg, 2012), and therapists vary significantly in success rates (Baldwin & Imel, 2013), are poor judges of negative outcomes (Chapman et al., 2012), and grossly overestimate their effectiveness (Walfish, McAlister, O'Donnell, & Lambert, 2012). Systematic client feedback offers one solution (Duncan, 2014). Several feedback systems have emerged (Castonguay, Barkham, Lutz, & McAleavey, 2013), but only two have randomized clinical trial support and are included in the Substance Abuse and Mental Health Administration’s National Registry of Evidence based Programs and Practices: The Outcome Questionnaire-45.2 System (Lambert, 2010) and the Partners for Change Outcome Management System (PCOMS; Duncan, 2012). This article presents the current status of the Partners for Change Outcome Management System, the psychometrics of the PCOMS measures, its empirical support, and its clinical and training applications. Future directions and implications of PCOMS research, training, and practice are detailed. Finally, we propose that systematic feedback offers a way, via large scale data collection, to re-prioritize what matters to psychotherapy outcome, reclaim our empirically validated core values and identity, and change the conversation from a medical model dominated discourse to a more scientific, relational perspective.
This study examined the effects of using client feedback, known as the Partners for Change Outcome Management System (PCOMS), with couples undergoing psychotherapy. 46 heterosexual couples were randomly assigned to either a treatment as usual (TAU) condition or to a feedback condition where therapists received feedback on client progress and the therapeutic alliance at each session via the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). It was hypothesized that couples receiving feedback would have better outcomes, improve more quickly, and be more likely to meet the criteria for clinically significant change. Results from this study aimed to replicate previous research finding client feedback beneficial for couples therapy.
The original validation of the CORS for kids and the ORS for adolescents. Allowed the benefits of client based outcome feedback to expand to youth and family and paved the way to the current RCT with kids in the schools.
PCOMS as an Alternative to Psychiatric Diagnosis (Duncan, Sparks, & Timimi, 2...Barry Duncan
Part of an incredible series about diagnostic alternatives by the Journal of Humanistic Psychology edited by Sarah Kamens, Brent Dean Robbins, & Elizabeth Flanagan
Slone, N. C., Reese, R. J., Mathews-Duvall, S., & Kodet, J. (2015). Evaluating the Efficacy of client feedback in group psychotherapy. Group Dynamics: Theory, Research, and Practice, 19, 122-136. doi:10.1037/gdn0000026
PCOMS: A Viable Quality Improvement Strategy for Public Behavioral HealthBarry Duncan
This is the latest from the research team of the Heart and Soul of Change Project, published in the Journal of Consulting and Clinical Psychology. This study demonstrated that PCOMS is not only a viable quality improvement strategy but also that services to the poor and disenfranchised provided in a public behavioral setting, contrary to earlier research, can be as effective as those delivered in randomized clinical trials.
This document summarizes a study that analyzed written responses from clients who had completed couple therapy. The study explored how clients experienced therapy through their responses to open-ended questions about therapy at a 6-month follow-up. The responses were analyzed thematically and compared between clients whose therapists did or did not use systematic feedback. Most clients found personable, active therapists who maintained neutrality to be helpful. Some expressed dissatisfaction with lack of structure or challenge from therapists. Lack of flexibility in scheduling was also problematic. Clients who used feedback generally found it very helpful.
The first quasiexperiemental study of the ORS/SRS in a telephonic EAP company. Doubled outcomes and improved retension. Set the stage for the RCTs that followed
The Norway Couple Project: Lessons LearnedBarry Duncan
The document discusses lessons learned from studies on using client feedback to improve outcomes in couple therapy. A large randomized clinical trial in Norway found that routinely collecting and discussing client feedback on progress and the therapeutic alliance using brief measures led to better outcomes compared to treatment as usual. Specifically, couples receiving feedback showed greater improvement in their relationships and were less likely to deteriorate over time. The findings suggest incorporating systematic client feedback into routine practice can help therapists improve outcomes for couples across different therapy approaches.
When children and teens present with behaviour and emotional problems the lure of a quick fix is
understandable and drugs present a ready-made solution. Therapists are often hesitant to talk about
medication and defer to medical professionals. In this paper DUNCAN, SPARKS, MURPHY and MILLER
highlight the explosion in the use of psychotropic medications for children and teens. This trend flies in the
face of the American Psychological Association’s recommendation of the use of psychosocial interventions
as the first intervention of choice with children and teens. The reliability and validity of psychiatric diagnoses is
questioned, in particular against a background of fluctuations in child development and social adaptations,
and a compelling critique is provided of the current research findings on the effectiveness of psychotropic
medications including antidepressants and ADHD medications. Therapists are urged to shed their timidity
and discuss openly the risks and benefits of medication with the knowledge that there is empirical support
for psychosocial interventions as a first line approach. Recommendations are offered to engage clients as
central partners in developing solutions—medical or non-medical—that fit each child and each situation.
This study examined the psychometric properties of Dutch translations of the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Data was collected from 126 clients who completed a total of 1005 ORS and SRS assessments over multiple therapy sessions. Results found the Dutch translations had good internal consistency and test-retest reliability, similar to previous American studies. Scores on the ORS and SRS also converged with therapist satisfaction ratings. Additionally, SRS scores predicted later ORS scores, supporting the validity of both measures. Overall, the study provides preliminary support for using the Dutch ORS and SRS in cross-cultural settings.
This article discusses applying research on psychotherapy outcomes, which has shown that common factors like the therapeutic relationship are more influential than theoretical approach or techniques. The article proposes intentionally using the client's frame of reference to enhance common factors and collaboration. It suggests emphasizing the client's perceptions of their relationship with the therapist and understanding of their issues over theoretical perspectives. A client-directed process is outlined that de-emphasizes theory and maximizes common factors and the client's involvement.
Feedback condition achieved nearly four times the amount of clients reaching reliable or clinically significant change. Nearly a 50% less separation/divorce at rate at follow up.
Article by Dr Mary Haynes about her agency's journey to a recovery orientation via CDOI and PCOMS published in the SAMHSA Recovery to Practice Newsletter.
The article discusses the development and research supporting the Partners for Change Outcome Management System (PCOMS). PCOMS uses two brief measures - the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) - to collect feedback from clients at each session on their progress and the therapeutic alliance. The ORS and SRS were developed to be brief and feasible for routine use. Research shows providing therapists feedback based on these measures improves client outcomes compared to treatment as usual. The article outlines how PCOMS was developed and refined, presents supporting research on the measures' psychometrics and clinical usefulness, and discusses examples of implementing PCOMS in behavioral health settings.
This 2 page article, which appeared in The Iowa Psychologist, provides an ultra brief summary of what makes therapy effective (the common factors) and how we can get better at what do: namely, add PCOMS, harvest client existing resources, and rely on that neglected old friend, the therapeutic alliance.
Although many of you may not be interested in the psychometric details of the ORS and SRS, it does bear importantly on whether there are seen as credible. Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views with Halstead, Youn, and Armijo (2013), debating when a measure is too brief and when it is too long. Here is our paper. First regarding when a measure is too brief: There is no doubt that 45 items, 30 items, or even 19 items is psychometrically better than 4 items, and that the increased reliability and validity of longer measures likely result in better detection, prediction, and ultimate measurement of outcome. But how much better is the really the question. Are these differences clinically meaningful and do they offset the low compliance rates and resulting data integrity issues from missing data? These are the questions that require empirical investigation to determine how brief is too brief, although from my experience, the verdict has already been rendered. But when is a measure too long? The answer is simple: When clinicians won’t use it.
This article, "Casting a Wider Net in Behavioral Health Screening in Primary Care" found that the ORS identified more clients for behavioral healthcare consultation than the PHQ-9. A first step toward the upcoming RCT with PCOMS in an integrated setting.
Overview of PCOMS and couple and family therapy.
Duncan, B., & Sparks, J. (2017). The Partners for Change Outcome Management System. In J. L. Lebow, A. L. Chambers, & D. C. Breunlin (Eds.), Encyclopedia of Couple and Family Therapy (pp. 1-10). New York: Springer.
This is the validation study of the Group Session Rating Scale (GSRS). In a nutshell, this study found more than acceptable reliability and validity with not only an alliance measure but also with group climate and cohesiveness scales. The GSRS was also predictive of last session outcomes. An RCT comparing PCOMS to TAU in group therapy has been submitted.
This document summarizes a study on implementing a systematic client feedback protocol into a marriage and family therapy training program to improve trainee competence and accountability. The study describes how the program integrated continuous client feedback into coursework, clinical training, and supervision using an Outcome Management system. Research shows that incorporating client feedback improves client outcomes and therapist effectiveness. The program believes this approach will train therapists to be more accountable to clients and enhance services provided at their family therapy clinic.
PCOMS works with kids too!
Cooper, M., Stewart, D., Sparks, J., Bunting, L. (2013). School-based counseling using systematic feedback: A cohort study evaluating outcomes and predictors of change. Psychotherapy Research, 23, 474-488.
Our recent article about therapist effects in couple therapy. So what distinguished one therapist from another? Demographics didn’t matter but 2 other things did. First, that tried and true but neglected old friend, the alliance accounted for 50% of the differences among therapists. Those who formed better alliances across clients got better outcomes. And therapist specific experience with couples accounted for 25% of the differences. So, experienced therapists can take some solace that getting older does have its advantages—as long as it is specific to task at hand.
The Partners for Change Outcome Management System (PCOMS) uses brief scales completed by clients at each session to provide feedback on client progress and the therapeutic alliance. This allows clinicians to identify clients at risk for negative outcomes early. Five randomized clinical trials have shown that PCOMS significantly improves treatment outcomes and reduces costs by shortening treatment length and increasing provider productivity. Hundreds of organizations in the U.S. and other countries have implemented PCOMS, which involves clients in their care while respecting clinicians' time.
This document summarizes an approach called Outcome-Informed, Client-Directed therapy. It discusses how current estimates show around 50% of clients drop out of therapy and one-third to two-thirds do not benefit from usual strategies. The approach focuses on accurately identifying clients not responding to therapy early on through standardized measures of outcome and alliance. This allows therapists to address the lack of change and keep clients engaged in more effective treatment. Case examples are provided to demonstrate how routinely monitoring progress and the therapeutic relationship can improve outcomes.
The Norway Couple Project: Lessons LearnedBarry Duncan
The document discusses lessons learned from studies on using client feedback to improve outcomes in couple therapy. A large randomized clinical trial in Norway found that routinely collecting and discussing client feedback on progress and the therapeutic alliance using brief measures led to better outcomes compared to treatment as usual. Specifically, couples receiving feedback showed greater improvement in their relationships and were less likely to deteriorate over time. The findings suggest incorporating systematic client feedback into routine practice can help therapists improve outcomes for couples across different therapy approaches.
When children and teens present with behaviour and emotional problems the lure of a quick fix is
understandable and drugs present a ready-made solution. Therapists are often hesitant to talk about
medication and defer to medical professionals. In this paper DUNCAN, SPARKS, MURPHY and MILLER
highlight the explosion in the use of psychotropic medications for children and teens. This trend flies in the
face of the American Psychological Association’s recommendation of the use of psychosocial interventions
as the first intervention of choice with children and teens. The reliability and validity of psychiatric diagnoses is
questioned, in particular against a background of fluctuations in child development and social adaptations,
and a compelling critique is provided of the current research findings on the effectiveness of psychotropic
medications including antidepressants and ADHD medications. Therapists are urged to shed their timidity
and discuss openly the risks and benefits of medication with the knowledge that there is empirical support
for psychosocial interventions as a first line approach. Recommendations are offered to engage clients as
central partners in developing solutions—medical or non-medical—that fit each child and each situation.
This study examined the psychometric properties of Dutch translations of the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Data was collected from 126 clients who completed a total of 1005 ORS and SRS assessments over multiple therapy sessions. Results found the Dutch translations had good internal consistency and test-retest reliability, similar to previous American studies. Scores on the ORS and SRS also converged with therapist satisfaction ratings. Additionally, SRS scores predicted later ORS scores, supporting the validity of both measures. Overall, the study provides preliminary support for using the Dutch ORS and SRS in cross-cultural settings.
This article discusses applying research on psychotherapy outcomes, which has shown that common factors like the therapeutic relationship are more influential than theoretical approach or techniques. The article proposes intentionally using the client's frame of reference to enhance common factors and collaboration. It suggests emphasizing the client's perceptions of their relationship with the therapist and understanding of their issues over theoretical perspectives. A client-directed process is outlined that de-emphasizes theory and maximizes common factors and the client's involvement.
Feedback condition achieved nearly four times the amount of clients reaching reliable or clinically significant change. Nearly a 50% less separation/divorce at rate at follow up.
Article by Dr Mary Haynes about her agency's journey to a recovery orientation via CDOI and PCOMS published in the SAMHSA Recovery to Practice Newsletter.
The article discusses the development and research supporting the Partners for Change Outcome Management System (PCOMS). PCOMS uses two brief measures - the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) - to collect feedback from clients at each session on their progress and the therapeutic alliance. The ORS and SRS were developed to be brief and feasible for routine use. Research shows providing therapists feedback based on these measures improves client outcomes compared to treatment as usual. The article outlines how PCOMS was developed and refined, presents supporting research on the measures' psychometrics and clinical usefulness, and discusses examples of implementing PCOMS in behavioral health settings.
This 2 page article, which appeared in The Iowa Psychologist, provides an ultra brief summary of what makes therapy effective (the common factors) and how we can get better at what do: namely, add PCOMS, harvest client existing resources, and rely on that neglected old friend, the therapeutic alliance.
Although many of you may not be interested in the psychometric details of the ORS and SRS, it does bear importantly on whether there are seen as credible. Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views with Halstead, Youn, and Armijo (2013), debating when a measure is too brief and when it is too long. Here is our paper. First regarding when a measure is too brief: There is no doubt that 45 items, 30 items, or even 19 items is psychometrically better than 4 items, and that the increased reliability and validity of longer measures likely result in better detection, prediction, and ultimate measurement of outcome. But how much better is the really the question. Are these differences clinically meaningful and do they offset the low compliance rates and resulting data integrity issues from missing data? These are the questions that require empirical investigation to determine how brief is too brief, although from my experience, the verdict has already been rendered. But when is a measure too long? The answer is simple: When clinicians won’t use it.
This article, "Casting a Wider Net in Behavioral Health Screening in Primary Care" found that the ORS identified more clients for behavioral healthcare consultation than the PHQ-9. A first step toward the upcoming RCT with PCOMS in an integrated setting.
Overview of PCOMS and couple and family therapy.
Duncan, B., & Sparks, J. (2017). The Partners for Change Outcome Management System. In J. L. Lebow, A. L. Chambers, & D. C. Breunlin (Eds.), Encyclopedia of Couple and Family Therapy (pp. 1-10). New York: Springer.
This is the validation study of the Group Session Rating Scale (GSRS). In a nutshell, this study found more than acceptable reliability and validity with not only an alliance measure but also with group climate and cohesiveness scales. The GSRS was also predictive of last session outcomes. An RCT comparing PCOMS to TAU in group therapy has been submitted.
This document summarizes a study on implementing a systematic client feedback protocol into a marriage and family therapy training program to improve trainee competence and accountability. The study describes how the program integrated continuous client feedback into coursework, clinical training, and supervision using an Outcome Management system. Research shows that incorporating client feedback improves client outcomes and therapist effectiveness. The program believes this approach will train therapists to be more accountable to clients and enhance services provided at their family therapy clinic.
PCOMS works with kids too!
Cooper, M., Stewart, D., Sparks, J., Bunting, L. (2013). School-based counseling using systematic feedback: A cohort study evaluating outcomes and predictors of change. Psychotherapy Research, 23, 474-488.
Our recent article about therapist effects in couple therapy. So what distinguished one therapist from another? Demographics didn’t matter but 2 other things did. First, that tried and true but neglected old friend, the alliance accounted for 50% of the differences among therapists. Those who formed better alliances across clients got better outcomes. And therapist specific experience with couples accounted for 25% of the differences. So, experienced therapists can take some solace that getting older does have its advantages—as long as it is specific to task at hand.
The Partners for Change Outcome Management System (PCOMS) uses brief scales completed by clients at each session to provide feedback on client progress and the therapeutic alliance. This allows clinicians to identify clients at risk for negative outcomes early. Five randomized clinical trials have shown that PCOMS significantly improves treatment outcomes and reduces costs by shortening treatment length and increasing provider productivity. Hundreds of organizations in the U.S. and other countries have implemented PCOMS, which involves clients in their care while respecting clinicians' time.
This document summarizes an approach called Outcome-Informed, Client-Directed therapy. It discusses how current estimates show around 50% of clients drop out of therapy and one-third to two-thirds do not benefit from usual strategies. The approach focuses on accurately identifying clients not responding to therapy early on through standardized measures of outcome and alliance. This allows therapists to address the lack of change and keep clients engaged in more effective treatment. Case examples are provided to demonstrate how routinely monitoring progress and the therapeutic relationship can improve outcomes.
Here is a recent chapter I did making the case for a relational perspective in therapeutic services (Duncan, B. (2014). The person of the therapist: One therapist’s journey to relationship. In K. J. Schneider, J. F. Pierson, & J. F.T. Bugental (Eds.). The Handbook of Humanistic Psychology: Leading Edges in Theory, Practice, and Research (2nd ed.) (pp. 457-472). New York: Sage Publications.
THIS CHAPTER DISCUSSES
•The empirical evidence supporting a strengths-based approach
•Specific practice guidelines for recruiting client resources to promote change
•The link between pluralistic counselling and a focus on client strengths
Barry's standard handouts providing a narrative description of what he presents. Includes a discussion of the common factors and the Partners for Change Outcome Management System
NCBI Bookshelf. A service of the National Library of Medicine,.docxvannagoforth
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Institute of Medicine (US) Roundtable on Value & Science-Driven Health Care; Yong PL, Olsen LA, McGinnis
JM, editors. Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes, and Innovation.
Washington (DC): National Academies Press (US); 2010.
5 Approaches to Improving Value—Provider and Manufacturer
Payments
INTRODUCTION
Payment design, coverage policies, reimbursement rules, and other financial incentives and
disincentives are powerful motivators when attempting to steer the healthcare system toward
more desirable care patterns (Guterman et al., 2009). Experiments with payment design and
coverage and reimbursement policies are currently going on in both public and private healthcare
sectors, with varying results. Speakers in this session of the workshop explored current payment
design experiments and discussed the efficacy of utilizing these reimbursement tools to improve
the value received from health care.
In this chapter, Carolyn M. Clancy details the pay-for-performance (P4P) model, an effort to
more explicitly link provider payments to quality of care. She highlights the lack of coherent
approaches to P4P and the variable success this approach has had in fundamentally changing
provider practice patterns. For example, while financial incentives for individual physicians have
shown that P4P can induce quality improvements for diabetic patients (Beaulieu and Horrigan,
2005), group-level incentives have had no impact on mammography screening or hemoglobin A
testing rates (Rosenthal et al., 2005). After underscoring that the current incentive system and
healthcare infrastructure fail to accommodate the achievement of real efficiency and quality, she
outlines recommendations for rethinking medical training, measurement, system design, and the
reward system.
Building on Clancy’s recommendations, Donald A. Sawyer identifies how the current healthcare
system stymies innovation in product development. He suggests refocusing the myopic view of
innovation on the horizon of long-term health improvements and financial savings. Reed V.
Tuckson discusses the alignment of manufacturers, technologists, payers, patients, and providers
necessary to establish a system that continues to provide incentives for innovation and maintains
an open market for the development of promising but unproven interventions. He elaborates
specifically on a joint effort between UnitedHealth Group and the American College of
Cardiology to develop appropriateness criteria for cardiac single-photon emission computed
tomography myocardial perfusion imaging—a new and very expensive technology—based on
best evidence as an example of how the interests of diverse stakeholder groups could be aligned.
In conclusion, Steven D. Pearson likens coverage and reimbursement tools to a blunt knife that
lacks subtlety in effecting value improvements, bu ...
This document discusses how to develop a PICO question to help determine the most relevant information for deciding on an evidence-based intervention for a client. It provides examples of factors to consider for the patient/client population (P), intervention/treatment (I), comparison intervention (C), and outcomes (O). It also introduces some key resources for finding evidence-based guidelines and systematic reviews, such as those from SAMHSA and Cochrane, to help answer PICO questions and identify best practices. Stakeholder involvement is emphasized when implementing a new evidence-based practice.
This document summarizes a discussion with an expert panel about the challenges of prior authorizations for managed care organizations and strategies to minimize the burden. The experts agree that prior authorizations pose a significant administrative burden for all parties involved and can delay needed care. However, they are important for managing healthcare costs. Suggested best practices to reduce the burden include regularly reviewing whether authorizations are still necessary, streamlining processes, educating providers and patients, and integrating electronic medical records. The challenges of unclear or conflicting guidelines are also discussed.
5 tips on how to select a prom for your study presentation notesKeith Meadows
The document provides 5 tips for selecting a patient reported outcome measure (PROM) for a study:
1. Always have a clear hypothesis about what you want to measure to help identify the appropriate PROM.
2. Ensure the content and individual items of the PROM are relevant to the patient population and disease being studied.
3. Consider if the PROM will be acceptable to complete for participants, considering length, time, and design.
4. Select a PROM that has been developed scientifically with evidence of reliability and validity.
5. Be able to correctly interpret the PROM data and results, and consider collaborating with an expert if needed.
Can Revalidation Deliver What the Public Expects?IAMRAreval2015
This document discusses public expectations of regulatory revalidation of clinicians and whether revalidation can deliver on those expectations. It notes that public expectations are modest, focusing more on access to care than quality or outcomes. It also discusses different definitions of competency and the complexity of problems in healthcare. While revalidation aims to maintain competency, it has limitations as practice is continuous but revalidation is periodic. The document suggests that for revalidation to meet public expectations, it would need to take a systems approach and include organizational assessments in addition to individual assessments. It also raises the possibility of alternative approaches to evaluation that focus more on intrinsic motivation and attitudes rather than just knowledge and skills.
White Paper: Breakthrough Behavioral NetworkMark Gall
A specialty provider network for mental health services.
The impressive clinical improvement for
Breakthrough patients is driving efficient
treatment episodes vs. other systems of care.
Quality circles originated in Japan after World War II and were inspired by W. Edwards Deming. Quality circles involve voluntary small groups of 6-12 employees who meet regularly to identify improvements in their work area. In healthcare, quality circles are used to (1) identify outstanding features of care, (2) identify obstacles to change, and (3) identify the need for more research. Examples of using quality circles in healthcare include reducing hospital-acquired infections, improving job satisfaction, and enhancing communication.
No evidence for demand characteristics or social desirability with the Session Rating Scale.
Reese, R. J., Gillaspy, J. A., Owen, J. J., Flora, K. L., Cunningham, L. E., Archie, D., & Marsden, T. (2013). The influence of demand characteristics and social desirability on clients’ ratings of the therapeutic alliance. Journal of Clinical Psychology, 69, 696-709.
Assignment DescriptionA reputable hospital has high quality .docxluearsome
Assignment Description
A reputable hospital has high quality ratings from patient satisfaction surveys but is still losing market share. For many years, health care organizations, as well as traditional businesses, have been frustrated that high customer satisfaction scores do not necessarily lead to higher levels of profitability or sales.
Prepare a report examining this phenomenon that address the following elements:
Evaluate and explain inconsistency between customer satisfaction scores and profitability and why it tends to exist in health care organizations.
Apply the statistical procedures discussed in class to support (or refute) the inconsistency.
Assess price vs. quality of services as well as the impact of insurance or managed care contracts on a hospital's market share, regardless of patient satisfaction levels.
Explain how you could use high patient satisfaction results to your advantage when negotiating a new managed care contract for the hospital. Discuss ethical issues involved when presenting results.
Discuss how qualitative and quantitative data can be used to help this hospital improve market share.
The body of the resultant report should be 5–7 pages and include at least 5 relevant peer-reviewed academic or professional references published within the past 5 years.
Library Resources:
Statistical Analysis 1 Below is a list of articles and summary descriptions on effective communication in health care. Click here to use the online library to search for the complete articles. Article 1 The increased use of meta-analysis in systematic reviews of health care interventions has highlighted several types of bias that can arise during the completion of a randomized controlled trial. Study publication bias and outcome reporting bias have been recognized as potential threats to the validity of meta-analysis and can make the readily available evidence unreliable for decision making. This update reviews and summarizes the evidence from cohort studies that have assessed study publication bias or outcome reporting bias in randomized controlled trials. Twenty studies were eligible, of which four were newly identified in this update. Only two followed the cohort all the way through from protocol approval to information regarding the publication of outcomes. Fifteen of the studies investigated study publication bias and five investigated outcome reporting bias. Three studies have found that statistically significant outcomes had higher odds of being fully reported as compared to nonsignificant outcomes (range of odds ratios: 2.2–4.7). In comparing trial publications to protocols, it was found that 40–62% of studies had at least one primary outcome that was changed, introduced, or omitted. It was decided not to undertake meta-analysis because of the differences between studies. This update does not change the conclusions of the review in which 16 studies were included. Direct empirical evidence for the existence of study publica ...
Emma logsdon· 4· 5 the six challenges for resigning health cssuser774ad41
The document discusses six key challenges for healthcare organizations undergoing redesign: (1) redesigning care processes, (2) incorporating performance measurements, (3) managing clinical knowledge and skills, (4) making effective use of information technologies, (5) coordinating care across settings, and (6) developing effective teams. The author believes redesigning care processes is the most important challenge because it impacts all the others. Other top challenges include incorporating performance measurements, managing clinical knowledge, and using information technologies effectively. The author argues that addressing these challenges will help healthcare organizations provide better, more efficient care.
This document discusses quality improvement and patient safety in anesthesia. It defines key terms like quality improvement, continuous quality improvement and differentiates it from traditional quality assurance. It outlines frameworks for improvement like the Model for Improvement and discusses tools used for quality improvement like Lean methodology, Six Sigma and PDSA cycles. It discusses important measures for quality improvement like process, outcome and balancing measures. Methods for analyzing and displaying quality improvement data like control charts and dashboards are described. Sources of quality improvement information and the importance of incident reporting are also summarized.
Do people fill out the SRS differently IF the therapist is in the room?Scott Miller
This study examined how demand characteristics and social desirability may influence clients' ratings of the therapeutic alliance. 102 clients from two university counseling centers were randomly assigned to one of three conditions for providing alliance feedback: immediate feedback where ratings were discussed with the therapist, next session feedback where ratings were private and discussed later, and no feedback where ratings were private and not shared. The study found no significant differences in alliance scores across the feedback conditions and scores were not correlated with social desirability but were correlated with an established alliance measure, providing evidence that scores were not inflated due to demand characteristics.
This document summarizes key steps medical groups need to take to gain physician support for transitioning to value-based care models. The most important initial step is meeting physicians' basic needs to reduce stress in their work environments. Next, groups must effectively communicate the rationale for changing to value-based care. They also need to realign compensation to reward improved outcomes. Additional steps include reducing clinical variation, coordinating care between specialties, promoting team-based care, developing physician leaders, and investing in leadership training. Taking these steps will help ensure medical groups have physician buy-in, which is critical for successfully transitioning to value-based payment models.
Research studies show thatevidence-based practice(EBP) leads t.docxronak56
This annotated bibliography summarizes 6 research articles on learning and development challenges facing first-generation college students. The articles address topics like social and academic integration, the impact of family support, and factors influencing persistence. A critical analysis compares the studies' populations, settings, strategies, and conclusions. Overall, the research highlights both opportunities and barriers first-generation students face in their transition to college. Recommendations from this research will inform strategies to design an educationally effective environment for this student group.
This document outlines the process of clinical audit, which involves comparing aspects of patient care against explicit criteria to improve outcomes. It discusses establishing structure, measuring processes, and evaluating outcomes. The document also describes the audit cycle of preparing, selecting criteria, measuring performance, making improvements, and sustaining them over time. Clinical audit is presented as a way for healthcare professionals and organizations to critically examine practices and ensure patients receive optimal care.
This document discusses evidence-based practice and provides information on different types of evidence available, including experimental studies, systematic reviews, and guidelines. It explains that evidence-based practice aims to provide an objective basis for practice by evaluating available evidence. The document also discusses how to search for evidence, including using keywords and databases, as well as the importance of developing a search strategy and documenting the search process.
Similar to Duncan & Sparks Ch 5 of Cooper & Dryden (20)
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
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Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
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it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
Executive Directors Chat Leveraging AI for Diversity, Equity, and Inclusion
Duncan & Sparks Ch 5 of Cooper & Dryden
1. 5
Systematic Feedback
through the Partners
for Change Outcome
Management System
(PCOMS)
Barry L. Duncan1
and
Jacqueline A. Sparks
However beautiful the strategy, you should occasionally look at the results.
Sir Winston Churchill
THIS CHAPTER DISCUSSES
• Systematic feedback and the Partners for Change Outcome Management
System (PCOMS)
• PCOMS as a way to truly privilege clients, include them as full partners in
decision-making and operationalize social justice and a pluralistic approach
Psychotherapy is a good news, bad news scenario. The good news is that therapy
works – the average treated person is better off than about 80% of the untreated
sample. The bad news is that, despite overall efficacy, many clients do not benefit,
1
Correspondence should be directed to Barry L.Duncan,Psy.D.,PO Box 6157,Jensen Beach,
Florida 34957 USA or barrylduncan@comcast.net. Duncan is a co-holder of the copyright
of the PCOMS family of instruments.The measures are free for individual use but Duncan
receives royalties from licences issued to groups and organizations. In addition, the web-based
application of PCOMS, BetterOutcomesNow.com is a commercial product and he receives
profits based on sales.
05_Cooper & Dryden_Ch_05.indd 55 10-Aug-15 5:16:51 PM
2. 56 The handbook of pluralistic counselling and psychotherapy
dropouts are a problem, and therapists vary significantly in success rates, are poor
judges of client negative outcomes and don’t have a clue about their effectiveness
(Duncan, 2014).
The Partners for Change Outcome Management System (PCOMS) offers a solu-
tion to these problems (Duncan, 2012). PCOMS employs two, four-item scales: one
focuses on outcome (the Outcome Rating Scale) and the other assesses the therapeu-
tic alliance (the Session Rating Scale).It includes a real-time collaborative comparison
of client views of outcome with an expected treatment response that serves as a
yardstick for gauging client progress and signalling when change is not occurring as
predicted.With this alert, counsellors and clients have an opportunity to shift focus,
re-visit goals, or alter interventions before deterioration or dropout. PCOMS has
been shown to improve outcomes in five randomized controlled trials (RCT) and
is included in the Substance Abuse and Mental Health Services Administration’s
(SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP).
PCOMS is one approach of what is called systematic feedback.Although systematic
feedback systems vary significantly in the measures used,empirical support and clinical
processes,all share the desire to measure the client’s response to service (the outcome),
and feed that information back to the therapist (or to both client and counsellor) to
enhance the possibility of a positive outcome.Two other systems are worthy of note
and exploration. First is the Outcome Questionnaire-45.2 System (OQ; Lambert,
2010). Michael Lambert is the pioneer of systematic feedback, evolving the idea of
outcome measurement to a ‘real time’ feedback process with a proven track record
of improving outcomes. The central measure is the OQ-45, a self-report measure
with 45 items targeting symptoms, emotional states, interpersonal relationships and
social role performance.With seven RCTs supporting it, the OQ System is the only
other system included in the SAMHSA National Registry. For more information,
see www.oqmeasures.com. Second is the Clinical Outcomes in Routine Evaluation-
Outcome Measure (CORE-OM; Barkham, Hardy, & Mellor-Clark, 2010).This is a
practical and widely used system in the UK.The central measure is the CORE-OM,
a 34-item self-report questionnaire, tapping the domains of subjective well-being,
problems, functioning and risk. It is administered before and after therapy (10- and
5-item versions are used for tracking in between). For more information, see www.
coreims.co.uk.
If someone told you that by having your clients answer four brief questions at the
beginning and end of each session you triple their chances of having a success-
ful outcome, would you say: ‘Na, too much trouble?’That’s exactly what PCOMS
brings to the table.A meta-analytic review (Lambert & Shimokawa, 2011) of three of
the five PCOMS studies (N = 558) reported that clients in the feedback group had
3.5 times higher odds of experiencing reliable change and less than half the chance
of experiencing deterioration than treatment as usual (TAU).This chapter intends to
give you enough about the Partners for Change Outcome Management System to
get you started. In addition to its empirical support and feasibility, PCOMS offers a
way to operationalize a therapy that privileges the client,prioritizes the relationship and
seeks full partnership with clients about all decisions that affect their care – or in other
words, a pluralistic approach.
05_Cooper & Dryden_Ch_05.indd 56 10-Aug-15 5:16:51 PM
3. 57Systematic feedback through the PCOMS
PCOMS AND A PLURALISTIC APPROACH
To exchange one orthodoxy for another is not necessarily an advance. The
enemy is the gramophone mind, whether or not one agrees with the record that
is being played at the moment.
George Orwell
PCOMS boils down to this: partnering with clients to identify those who aren’t
responding and addressing the lack of progress in a proactive way that keeps cli-
ents engaged while new directions are collaboratively sought. Five RCTs, the largest
benchmarking study ever conducted in public behavioural health, and a cohort study
have unequivocally shown that PCOMS improves outcomes with youth and adults,
in individual, couple and group therapy, with both mental health and substance abuse
problems, and with the impoverished and disenfranchised (for a review of these
studies conducted by the Heart and Soul of Change Project, see Duncan, 2014; to
download these studies, visit https://heartandsoulofchange.com).
Although PCOMS is designated as an evidence-based practice, it is not your
average evidence-based practice – not a specific treatment model for a specific cli-
ent diagnosis. PCOMS has demonstrated significant improvements for both clients
and counsellors regardless of therapist theoretical orientation or client diagnosis.
More importantly, PCOMS is evidence-based at the individual client–counsellor
level, promoting a partnership that monitors whether this approach provided by this
therapist is benefiting this client. In other words, it is evidence-based practice one client
at a time.
PCOMS, consequently, lines up very well with both a pluralistic perspective and
pluralistic practice (Cooper & McLeod,2011).A pluralistic perspective posits that differ-
ent clients are likely to benefit from different things, and that therapists should work
closely with clients to help them identify what they want from therapy and how they
might achieve it. Pluralistic practice is an approach to therapy based on a pluralistic per-
spective that draws on techniques from a multiple orientations, and is characterized
by ongoing negotiation with clients about the goals, tasks and methods of therapy.
PCOMS operationalizes a pluralistic approach in several ways.First,PCOMS does
not drag any theoretical baggage to the therapeutic journey – it neither explains client
problems nor offers any solutions.PCOMS is consequently pluralistic in its scope and
encourages an individually tailored therapy that emerges from the client’s idiosyn-
cratic strengths, cultural worldview and theory of change (Duncan, Solovey, & Rusk,
1992).When services are provided without intimate connection to those receiving
them and to their responses and preferences, clients become cardboard cut-outs, the
object of our professional deliberations.Valuing clients as credible sources of their
own experiences of progress and relationship allows clients to teach us how we can
be the most effective with them, consistent with a pluralistic perspective.
A pluralistic approach values dialogue and negotiation and PCOMS provides a
ready-made structure at the top and bottom of the hour for that to happen.It ensures
therapy’s match with a client’s preferred future via monitoring progress on the ORS.
05_Cooper & Dryden_Ch_05.indd 57 10-Aug-15 5:16:51 PM
4. 58 The handbook of pluralistic counselling and psychotherapy
And it provides a way to ensure therapy’s alignment with a client’s goals and preferred
way of achieving goals via monitoring the relationship with the SRS.Thus, PCOMS
promotes the values of social justice by privileging client voice over manuals and the-
ories enabling idiosyncratic and culturally responsive practice with diverse clientele.
Clients determine the fit and benefit of services as well as intervention preferences.
This is the essence of a pluralistic approach.
THE PARTNERS FOR CHANGE OUTCOME
MANAGEMENT SYSTEM
The only man I know who behaves sensibly is my tailor; he takes my measurements
anew each time he sees me. The rest go on with their old measurements and
expect me to fit them.
George Bernard Shaw
PCOMS embraces two known predictors of ultimate treatment outcome.Time and
again, studies reveal that the majority of clients experience the majority of change in
the first eight visits (e.g., Baldwin, Berkeljon,Atkins, Olsen, & Nielsen, 2009). 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. Monitoring change pro-
vides a tangible way to identify those who are not responding so that a new course can
be charted.A second robust predictor of change solidly demonstrated by a large body
of studies, is that taken-for-granted old friend, the therapeutic alliance. Clients who
highly rate their partnership with their therapists are more apt to remain in therapy
and benefit from it.
PCOMS starts with the Outcome Rating Scale (ORS; Miller, Duncan, Brown,
Sparks, & Claud, 2003) or the Child ORS (Duncan, Sparks, Miller, Bohanske,
& Claud, 2006), which is used for children aged 6–12 and their caregivers.
05_Cooper & Dryden_Ch_05.indd 58 10-Aug-15 5:16:52 PM
5. 59Systematic feedback through the PCOMS
Adolescents use the ORS (both measures are free for individual use and inexpensive
for groups; download at https://heartandsoulofchange.com).The ORS and CORS
are given at the beginning of a session and provide client-reported ratings of progress
(as well as caregiver ratings for youth). An inspection of Figure 5.1 reveals that the
ORS and CORS are visual analogue scales consisting of four 10 centimetre lines,
corresponding to four domains (individual, interpersonal, social and overall). Clients
place a mark on each line to represent their perception of their functioning in each
domain.Therapists use a 10 cm ruler (or available software) to sum the client’s total
score, with a maximum score of 40. Lower scores reflect more distress.
The Session Rating Scale (SRS) (Duncan et al., 2003) and Child SRS, both
four-item visual analogue scales covering the classic elements of the alliance (Bordin,
1979), are given toward the end of a therapy session.The CSRS is for children 6–12
years; adolescents use the SRS. Similar to the ORS, each line on the SRS or CSRS
is 10 cm and can be scored manually or electronically. Use of the SRS encourages all
client feedback, positive and negative, thus creating a safe space for clients to voice
their reactions to therapy and expectations for it.
THE CLINICAL PROCESS
PCOMS is a light-touch, checking-in process that usually takes about 5 minutes but
never over 10 to administer, score and integrate into the therapy. PCOMS works best
as a way to gently guide models and techniques toward the client’s perspective,with a
focus on outcome. Besides the brevity of its measures and feasibility for everyday use
FIGURE 5.1 The Outcome Rating Scale (ORS), Session Rating Scale (SRS), Child ORS and Child
SRS. Copyright 2000, 2002, 2003 and 2003, respectively by B. L. Duncan, S.D. Miller (for the ORS,
SRS, CORS, CSRS), and J.A. Sparks (for the CORS and CSRS). Reprinted with permission. For
examination only. Download free working copies at https://heartandsoulofchange.com.
05_Cooper & Dryden_Ch_05.indd 59 10-Aug-15 5:16:52 PM
6. 60 The handbook of pluralistic counselling and psychotherapy
in the demanding schedules of front-line clinicians, PCOMS is distinguished by its
routine involvement of clients in all aspects of counselling; client scores on the ORS
and SRS are openly shared and discussed at each administration. Client views of pro-
gress serve as a basis for beginning therapeutic conversations, and their assessments of
the alliance mark an endpoint to the same.With this transparency, the measures pro-
vide a mutually understood reference point for reasons for seeking service, progress
and engagement.
Given that at its heart PCOMS is a collaborative intervention, it is important that
clients understand two points: (1) the ORS (or CORS) is a way to make sure that
the client’s voice is not only heard but remains central; and (2) the ORS will be used
to track outcome in every session. In the first meeting, the ORS pinpoints where
the client sees him- or herself, allowing for an ongoing comparison in later sessions.
Since everything about PCOMS is 100% transparent, the task after the score is
totalled is to make sense of it with the final authority – the client.The‘clinical cutoff’
facilitates a shared understanding of the ORS and is often a step toward connect-
ing client marks on the ORS to the reason for services.Twenty-five is the cutoff for
adults, meaning that, on average, persons seeking therapy will fall below that, and
those not typically seeking counselling will score above. For those scoring below the
cutoff, the therapist can assure them that they made a good decision to come in. For
those scoring above the cutoff, counsellors can simply validate their score by saying
that it looks like things are going pretty well, which leads to the next logical
question – what are the reasons for meeting now? But importantly, even if clients
score above the cutoff there will be one scale lower than the rest that typically signals
the reason for service.
Therapist: What I do is I just measure this up, it’s four 10 cm lines and it gives
a score from 0 to 40 and I just pull out this ruler and add up the
scores, and then I will tell you about what this says and you can tell
me whether it is accurate or not, and then we will have an anchor
point to measure each time and see if you’re getting what you came
here to get … Okay, you scored a 19.8. And what that means is that
this scale, the Outcome Rating Scale, has a cutoff of 25 and people
who score under 25 tend to be those who wind up talking to peo-
ple like me, they’re looking for something different in their lives. You
scored about the average intake score of persons who enter therapy,
so you’re in the right place. And it’s not hard to look at this and see
pretty quickly that it’s the family/close relationship area is what you
are struggling with the most right now. Does that make sense?
Client: Yes, definitely.
Therapist: So what do you think would be the most useful thing for us to talk
about?
Client: Well, I am in the middle of divorce and struggling with figuring this
out …
Give the score, say what it might mean, and look for feedback to see if it fits.What
you will find in 99 out of 100 administrations in the first meeting is that clients
05_Cooper Dryden_Ch_05.indd 60 10-Aug-15 5:16:52 PM
7. 61Systematic feedback through the PCOMS
mark lowest the scale that they are there to talk about. The above client did just
that.The initial ORS score is an instant snapshot of how the client views him- or
herself.It brings an understanding of the client’s experience to the opening minutes
of a session.
Unlike other outcome scales, the ORS is not a list of symptoms or problems
checked by clients or others on a Likert Scale. It is individually tailored by design.
This requires that the counsellor ensure that the ORS represents both the cli-
ent’s experience and the reasons for service – that the general framework of client
distress evolves into a specific account of the work done in therapy. Clients usu-
ally mark lowest the scale that represents the reason they are seeking therapy, and
often connect that reason to the mark they’ve made without prompting from the
therapist. Other times, the counsellor needs to clarify the connection between the
client’s descriptions of the reasons for services and the client’s marks on the ORS.
At the moment clients connect the marks on the ORS with the situations that
prompt their seeking help, the ORS becomes a meaningful measure of progress and
a potent clinical tool.And that moment facilitates the next question:‘What do you
think it will take to move your mark just one centimetre to the right; what needs
to happen out there and in here?’
With the same client as above:
Therapist: If I am getting this right, you said that you are struggling with the
divorce, specifically about why it happened and your part in it so you
are looking to explore this and gain some insight into what perhaps
was your contribution. You marked the Interpersonally scale the
lowest [Therapist picks up the ORS]. Does that mark represent this
struggle and your longing for some clarity?
Client: Yes.
Therapist: So, if we are able to explore this situation and reach some insights
that resonate with you, do you think that it would move that mark to
the right?
Client: Yes, that is what I am hoping for and that’s what I think will help me.
I know I wasn’t perfect in the relationship and I want to understand
my part. I already know his part!
The SRS (or CSRS) opens space for the client’s voice about the alliance. It is given
at the end of the meeting, leaving enough time for discussing the client’s responses.
Given that clients tend to score high on alliance measures, a total score below 36
signals the possibility of a problematic alliance and prompts a frank discussion about
steps needed to increase client connection to the therapist and the process.Regardless
of the score, the SRS focuses attention on the alliance, and therefore helps build
strong ones.
After the first session, PCOMS simply asks: are things better?We are hoping for a
six-point increase on the ORS, what is called a reliable change, or a six-point increase
and crossing the clinical cutoff, what is called a clinically significant change. ORS scores
are used to engage the client in a discussion about progress, and more importantly,
what should be done differently if there isn’t any.When ORS scores increase,a crucial
05_Cooper Dryden_Ch_05.indd 61 10-Aug-15 5:16:52 PM
8. 62 The handbook of pluralistic counselling and psychotherapy
step to empower the change is to help clients see any gains as a consequence of their
own efforts.This requires an exploration of the clients’ perception of the relationship
between their own efforts and the occurrence of change (Duncan et al.,1992).When
clients have reached a plateau or what may be the maximum benefit they will derive
from counselling, planning for continued recovery outside of therapy can start.
A more important discussion occurs when ORS scores are not increasing.The
longer therapy continues without measurable change, the greater the likelihood of
drop out and/or poor outcome.The ORS stimulates such a conversation so that both
interested parties may struggle with the implications of continuing a process that is
yielding little or no benefit.Although addressed in each meeting in which it is appar-
ent that no benefit is occurring,later sessions gain increasing significance and warrant
additional action including referral of the client to another counsellor – what we have
called checkpoint conversations and last chance discussions (Duncan, 2014).
In a typical outpatient setting,checkpoint conversations are conducted at the third
to sixth session and last-chance discussions are initiated in the sixth to ninth meeting.
This is simply saying that the trajectories observed in most outpatient settings sug-
gest that most clients who benefit from services usually show it in sessions 3–6; and
if change is not noted by then, then the client is at a risk for a negative outcome.
The same goes for sessions 6–9 except that the urgency is increased, hence the term
‘last chance’.An available web-based system provides a more sophisticated identifica-
tion of clients at risk by comparing the client’s progress to the expected treatment
response of clients with the same intake score.
The progression of the conversation with clients who are not benefiting goes
from talking about whether something different should be done, to identifying what
can be done differently, to doing something different. Doing something different
can include, for example, inviting others from the client’s support system, using a
team,developing a different conceptualization of the problem,trying another therapy
approach, or referring to another counsellor or venue of service such as a religious
adviser or self-help group – whatever seems to be of value to the client.
CASE EXAMPLE
Ken
Ken, a 35-year-old construction supervisor, was convinced that he was going
crazy because panic attacks were becoming ever more intrusive. He scored a
14.2 on the ORS at intake, indicating a high level of distress. Ken said he was
at a loss about what to do and looked to the therapist for something to man-
age the anxiety. Trying to address his request, the therapist called up training
in CBT (see Chapter 9, this volume) and strategic therapy and suggested a
combination of relaxation training, challenging the beliefs that led to the panic,
and some strategic monitoring (symptom prescription). But nothing happened,
and none of these approaches seemed to resonate much with Ken – his scores
on the ORS hovered around 14.
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9. 63Systematic feedback through the PCOMS
So, in the fourth meeting, the therapist and client renegotiated, via the
approach scale on the SRS. Ken intimated that maybe he could try to understand
why he was having panic attacks. Ken also shared during this quiet negotiation
that in tough times he always talked to his dad, but his dad had passed away
some 6 months before. He noted that he felt alone in his struggles, although he
knew that really wasn’t true because his wife was supportive and he had some
good friends. The therapist enquired if Ken believed there was a connection
between his father’s death, his feeling of aloneness and the panic. Ken replied
with tears, and a quiet yes.
A different kind of discussion ensued, drawing on the therapist’s existential
training (see Chapter 11, this volume), of not only Ken’s confrontation of his
own mortality but also the incredible dread that accompanies the realization of
our essential aloneness in the world. A new theory of change evolved, one that
seemed to make a lot of sense within the four big existential givens: death,
freedom, isolation and meaninglessness. Ken found these conversations
useful, and after four more meetings his panic attacks subsided and ultimately
stopped; his ORS scores increased to 24.6 (a reliable change nearly to the
clinical cutoff).
What PCOMS brought to the table is that it spotlighted the lack of change.
Impossible to dismiss, it brought the risk of a negative outcome front and cen-
tre. Without the findings from the ORS, the therapist might have continued with
the same strategies for several more sessions, hoping that these reasonable
methods would eventually take hold. As it was, the evidence obtained through
PCOMS pushed both Ken and the therapist to explore different options.
This story, of course, says nothing about the value of CBT, strategic, or existentially
informed therapy – all approaches provide useful ideas to pursue. Rather, Ken’s
therapy illustrates that first identifying clients who are not responding, and then
re-exploring the client’s perspectives about change, things that resonate better with
the client, can enable different, more fruitful directions. This is what pluralistic, or
what we have called ‘client-directed’, counselling is all about.
LIMITATIONS OF PCOMS
Even though the research is compelling, most counsellors do not monitor outcomes.
There are several reasons. First, finding out how effective you really are can be a risky
business.You might learn something that you might not want to – but the only way
to get better is to know where you are now versus where you would like to be; to
aspire for the best results, and take action to get them. But the good news here is
that we know it works. In our large feedback study with couples, 9 of 10 therapists
improved their outcomes with feedback (Anker, Duncan, Sparks, 2009).
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10. 64 The handbook of pluralistic counselling and psychotherapy
Another reason is that,on the whole,counsellors don’t like the idea of‘assessment’
or numbers. But this is different because PCOMS invites clients into the inner circle,
amplifying their voices in any decisions about their care.The numbers don’t mean
reducing clients to statistics. Rather, the numbers represent clients’ own assessments
of progress. Without them, clients’ views do not stand a chance to be part of the
real record – that is, critical information that guides moment-by-moment, week-by-
week, decisions or evaluates eventual outcomes.
A third reason is that many believe they already know the information PCOMS is
designed to provide.In fact,in the couple study (Anker et al.,2009),all 10 of the thera-
pists indicated that they already informally acquired outcome and alliance information
and,moreover,that systematic feedback would not improve their effectiveness.Nine of
ten did improve their outcomes, so only one of them was correct.
Finally, a concern sometimes voiced before PCOMS is tried is that some clients
won’t want to do PCOMS. In truth, clients very rarely say ‘no’ to PCOMS when a
sincere, authentic therapist conveys that the ORS and the SRS are to ensure their
voice stays central as well as making sure they benefit. But the therapist has to believe
that this is true and use the measures in a way that makes them meaningful to the work.
If the ORS is treated as a perfunctory piece of paper that is not related to the thera-
peutic process,then clients will see it similarly.However,if the client persists in refusal
after further clarification of the purpose of PCOMS, then it is likely best to move on
with the session.
CONCLUSIONS
At bottom every man [sic] knows well enough that he is a unique being,
only once on this earth; and by no extraordinary chance will such a marvel-
lously picturesque piece of diversity in unity as he is, ever be put together
a second time.
Friedrich Nietzsche
Routinely measuring outcome and the alliance with every client ensures that neither
issue is left to chance.This allows both transparency and true partnership with clients,
keeping their perspectives the centrepiece. In addition, it serves as an early warning
device that identifies clients who are not benefiting so that the client and the therapist
can chart a different course.This, in turn encourages the counsellor to step outside of
business as usual, do new things and therefore continue to grow as a therapist. Finally,
PCOMS improves focus on what matters most to the client both in terms of what
needs to change outside of therapy as well as during the hour. Although it sounds
like hyperbole,identifying clients who are not benefiting is the single most important
thing a therapist can do to improve outcomes – 12 RCTs (both PCOMS and OQ
System) now support this assertion.
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11. 65Systematic feedback through the PCOMS
But it requires the therapist to show up. If the counsellor doesn’t authenti-
cally value clients’ perspectives and believe that they should be active participants,
PCOMS will fall flat. In addition, without therapist investment into the spirit of
partnership of the feedback process, little gain is likely to happen. It’s not enough
to flick the forms in the face of the client – the feedback must be used and allowed
to influence the work.
PCOMS and pluralistic practice call for a more sophisticated and empiri-
cally informed clinician who chooses from a variety of orientations and methods
to best fit client preferences and cultural values. Although there has not been
convincing evidence for differential efficacy among approaches, there is indeed
differential effectiveness for the client in the room now – therapists need expertise
in a broad range of intervention options, including evidence-based treatments,
but must remember that, however beautiful the strategy, one must occasionally
look at the results.
SUMMARY
The key points of this chapter are:
• Twelve RCTs (both OQ System and PCOMS) demonstrate that systematic
feedback improves outcomes by recapturing clients who are headed toward a
negative end.
• PCOMS is the only system that includes routine alliance monitoring and that is, by
design, intended to be collaborative and transparent.
• PCOMS operationalizes a pluralistic approach (and social justice) by providing a
methodology for individually tailoring counselling to client goals and preferences,
and privileging client perspectives over model and theory.
EXERCISES/POINTS FOR REFLECTION
1 Download the PCOMS family of measures from heartandsoulofchange.com
or pcoms.com. The measures are free for individual use. Simply click on ‘Get
measures’ on the homepage, indicate your understanding of the License
Agreement, register your email (no marketing materials sent), and download
the measures in 24 languages.
2 Watch the free webinars at heartandsoulofchange.com. Click on ‘PCOMS 101’
on the cascading slide or on ‘Training’ on the menu. ‘PCOMS Video’ is a good
place to start and includes the nuts and bolts of using the measures.
3 Reflect whether systematic feedback fits into your value system and can
become integrated into your authentic practice of psychotherapy. PCOMS (or
anything else) doesn’t ‘work’ without your investment of yourself and your
genuine desire to partner with clients and appreciate their feedback.
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12. 66 The handbook of pluralistic counselling and psychotherapy
FURTHER READING
https://heartandsoulofchange.com. Contains more than 250 free resources
including webinars, articles, chapters and slide handouts.
Duncan, B. (2014). On becoming a better therapist: evidence-based practice one
client at a time (2nd ed.). Washington, DC: American Psychological Association.
‘All in one’ source for PCOMS, the common factors, and how to become a
better therapist.
Duncan, B.L., Reese, R.J. (2012). Empirically supported treatments, evidence
based treatments, and evidence based practice. In G. Stricker T. Widiger
(Eds.), Handbook of psychology: Volume 8: Clinical psychology (2nd ed.,
pp. 977–1023). New York: Wiley. Comprehensive resource covering the
controversy about evidence based treatments.
Duncan, B., Sparks, J. (2010). Heroic clients, heroic agencies: partners for
change (2nd ed.). Jensen Beach, FL: Author. Practical, how-to ‘manual’ for
client-directed work and PCOMS that is consistent with a pluralistic approach.
The first edition (2002) presented the original articulation of the clinical use of
the ORS/SRS.
Kottler, J., Carlson, J. (2014). On being a master therapist: practicing what you
preach. New York: Wiley. Great resource from two renowned psychotherapists.
REFERENCES
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, 693–704.
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, 203–211.
Barkham, M., Hardy, G., Mellor-Clark, J. (2010). Developing and delivering practice-
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Bordin, E. (1979).The generalizability of the psychoanalytic concept of the working
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Cooper,M., McLeod,J.(2011).Pluralistic counselling and psychotherapy.London:Sage.
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Duncan,B.(2014).On becoming a better therapist:evidence based practice one client at a time
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(2003). The Session Rating Scale: preliminary psychometric properties of a
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