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.
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.
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 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.
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.
Duncan & Sparks Ch 5 of Cooper & DrydenBarry Duncan
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
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
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.
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
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.
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 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.
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.
Duncan & Sparks Ch 5 of Cooper & DrydenBarry Duncan
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
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
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.
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
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.
What Is Client Directed Outcome InformedScott Miller
Client Directed Outcome Informed (CDOI) clinical work privileges the client's perspective and uses their feedback to guide treatment in a partnership between client and provider. Several mental health and substance abuse treatment organizations that have implemented CDOI report improved outcomes like higher retention rates and lower costs from reduced sessions and cancellations. Research shows involving clients in decisions about their treatment and focusing on whether treatment is working improves success rates by an average of 65%.
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.
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.
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
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.
The document discusses PCOMS (Partners for Change Outcome Management System), an evidence-based practice designated by SAMHSA. PCOMS was developed by Dr. Barry Duncan and the Heart and Soul of Change Project to improve client outcomes. Better Outcomes Now (BON) is a web application that implements PCOMS's clinical process and was used in five randomized clinical trials demonstrating PCOMS's effectiveness. PCOMS incorporates robust predictors of therapeutic success like early client feedback and the therapeutic alliance into an outcome management system.
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.
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.
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.
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.
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.
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.
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.
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 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.
The document discusses research on whether using a continuous feedback system called the Partners for Change Outcome Management System (PCOMS) can improve psychotherapy outcomes. PCOMS involves clients completing brief measures after each session to assess treatment progress and the therapeutic relationship. Studies found that clients who used PCOMS with their therapists demonstrated statistically significant treatment gains compared to those receiving usual treatment and were more likely to experience reliable change in fewer sessions.
The 4th RCT demonstrating the power of feedback to improve outcomes--this time with group therapy of soldiers with substance abuse problems. All of the RCTs of PCOMS have been conducted by the Heart and Soul of Change Project
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.
What Is Client Directed Outcome InformedScott Miller
Client Directed Outcome Informed (CDOI) clinical work privileges the client's perspective and uses their feedback to guide treatment in a partnership between client and provider. Several mental health and substance abuse treatment organizations that have implemented CDOI report improved outcomes like higher retention rates and lower costs from reduced sessions and cancellations. Research shows involving clients in decisions about their treatment and focusing on whether treatment is working improves success rates by an average of 65%.
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.
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.
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
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.
The document discusses PCOMS (Partners for Change Outcome Management System), an evidence-based practice designated by SAMHSA. PCOMS was developed by Dr. Barry Duncan and the Heart and Soul of Change Project to improve client outcomes. Better Outcomes Now (BON) is a web application that implements PCOMS's clinical process and was used in five randomized clinical trials demonstrating PCOMS's effectiveness. PCOMS incorporates robust predictors of therapeutic success like early client feedback and the therapeutic alliance into an outcome management system.
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.
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.
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.
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.
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.
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.
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.
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 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.
The document discusses research on whether using a continuous feedback system called the Partners for Change Outcome Management System (PCOMS) can improve psychotherapy outcomes. PCOMS involves clients completing brief measures after each session to assess treatment progress and the therapeutic relationship. Studies found that clients who used PCOMS with their therapists demonstrated statistically significant treatment gains compared to those receiving usual treatment and were more likely to experience reliable change in fewer sessions.
The 4th RCT demonstrating the power of feedback to improve outcomes--this time with group therapy of soldiers with substance abuse problems. All of the RCTs of PCOMS have been conducted by the Heart and Soul of Change Project
This article argues that client perspectives have been overlooked in psychotherapy integration efforts. It proposes conducting therapy within the context of the client's own theory of change, which privileges the client's voice as the source of wisdom and solution. The client should be seen as the heroic driver of the therapeutic process, not just as an object of assessment and intervention by the therapist. Research shows that client factors such as strengths, perceptions of the therapeutic relationship, and resources account for the majority of improvement in therapy. Therefore, integration approaches should focus on understanding and incorporating the client's own ideas about the problem and how change occurs.
This document discusses what makes an effective or "master" therapist. It begins by arguing that psychotherapy is a relational endeavor dependent on the client and therapist's connection, not just evidence-based treatments. The most important thing a therapist can do is identify clients who are not benefiting and change course.
It then discusses four questions about what makes an effective therapist. In response to the first question about what they do, the author emphasizes routinely measuring outcomes and the therapeutic alliance to ensure client perspectives are central. For the second question about who they are, the author believes their belief in clients and psychotherapy's ability to create change is important.
In response to the third question about what defines an extraordinary therapist, the author argues
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
Most therapists want to improve their skills and help more clients. However, research shows that factors like personal therapy, specific treatment approaches, training, or experience do not necessarily correlate with better outcomes. After studying thousands of therapists over 15 years, one key factor was identified - "Healing Involvement", where therapists are fully engaged with clients through empathy, skills, efficacy, and handling difficulties constructively. This state can be achieved through career development improving skills over time, self-care reducing burnout, and connection to purpose and values in their work.
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.
Feedback informed treatment (fit) achieving(apa ip miller hubble seidel chow ...Scott Miller
1) The document discusses Feedback Informed Treatment (FIT), which uses routine monitoring of a client's progress and the therapeutic alliance to improve outcomes. Short scales like the Session Rating Scale and Outcome Rating Scale are used to gather feedback from clients.
2) Research shows that formal collection and discussion of client feedback doubles rates of reliable change, decreases dropout rates by 50%, and cuts deterioration rates by a third compared to treatment without feedback.
3) The feedback allows therapists to adjust their approach if a client is not progressing well or the alliance is weakening, in order to maximize the fit between client, therapist, and treatment for that individual.
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.
Enhancing Psychotherapy Process With Common Factors Feedback.docxkhanpaulita
Enhancing Psychotherapy Process With Common Factors Feedback:
A Randomized, Clinical Trial
Andrew S. McClintock, Matthew R. Perlman, Shannon M. McCarrick,
Timothy Anderson, and Lina Himawan
Ohio University
In this study, we developed and tested a common factors feedback (CFF) system. The CFF system was
designed to provide ongoing feedback to clients and therapists about client ratings of three common
factors: (a) outcome expectations, (b) empathy, and (c) the therapeutic alliance. We evaluated the CFF
system using randomized, clinical trial (RCT) methodology. Participants: Clients were 79 undergradu-
ates who reported mild, moderate, or severe depressive symptoms at screening and pretreatment
assessments. These clients were randomized to either: (a) treatment as usual (TAU) or (b) treatment as
usual plus the CFF system (TAU � CFF). Both conditions entailed 5 weekly sessions of evidence-based
therapy delivered by doctoral students in clinical psychology. Clients completed measures of common
factors (i.e., outcome expectations, empathy, therapeutic alliance) and outcome at each session. Clients
and therapists in TAU � CFF received feedback on client ratings of common factors at the beginning of
Sessions 2 through 5. When surveyed, clients and therapists indicated that that they were satisfied with
the CFF system and found it useful. Multilevel modeling revealed that TAU � CFF clients reported
larger gains in perceived empathy and alliance over the course of treatment compared with TAU clients.
No between-groups effects were found for outcome expectations or treatment outcome. These results
imply that our CFF system was well received and has the potential to improve therapy process for clients
with depressive symptoms.
Public Significance Statement
In this study, we developed a system that provides ongoing feedback to clients and therapists about
what is transpiring in therapy. Results suggest that the feedback system may help to improve the
process of treatment for clients with depressive symptoms.
Keywords: common factors, feedback, empathy, alliance, randomized clinical trial
A growing body of research attests to the utility and effectiveness
of outcome feedback (Connolly Gibbons et al., 2015; De Jong et al.,
2014; Shimokawa, Lambert, & Smart, 2010). In outcome feedback
systems, client progress is monitored and reviewed by therapists (and,
in some cases, by clients as well) to guide ongoing treatment (Lam-
bert, 2007). Specifically, these systems collect distress/symptomatol-
ogy data from clients on a routine basis, and then compare these data
with norms or expected treatment responses (see Lambert, 2007; Lutz
et al., 2006). When a client is off-track (i.e., is projected to have a
relatively poor treatment response), the therapist is alerted and is
then typically provided with strategies for improving quality of
care (Lambert et al., 2004; Miller, Duncan, Sorrell, & Brown,
2005).
Although outcome feedback has demonstrated efficacy (e..
Article in Division 29's journal, psychotherapy that reviews the research on routine outcome monitoring, arguing that current efforts are at risk for repeating the history of failed efforts to improve the outcome of psychotherapy.
Clinical supervision its influence on client-rated working alliance and clie...Daryl Chow
This study evaluated the impact of clinical supervision on client working alliance and symptom reduction in the brief treatment of major depression. Therapists were randomly assigned to receive either alliance skill-focused or alliance process-focused supervision, or to receive no supervision. Both supervision conditions had a significant positive effect on working alliance, symptom reduction, and treatment retention compared to the no supervision condition. However, there was no significant difference found between the two supervision conditions. The findings provide preliminary evidence that clinical supervision can improve client outcomes, but more research is still needed to separate the effects of different supervision approaches.
[Ann Emerg Med. 2009;53:685-687.]
Systematic Review Source
This is a systematic review abstract, a regular feature of the Annals' Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area.
The source for this systematic review abstract is: O'Brien MA, Freemantle N, Oxman AD, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001;(2):CD003030.
The Annals' EBEM editors helped prepare the abstract of this Cochrane systematic review, as well as the Evidence-Based Medicine Teaching Points.
Objective
To determine the effects of continuing educational meetings on professional practice and health care outcomes.
Data Sources
The Cochrane Effective Practice and Organization of Care Group specialized register, MEDLINE, and the Research and Development Resource Base in Continuing Medical Education were searched. The reference list of related systematic reviews and all articles obtained were reviewed. This review was amended in 2006 from the previous one published in 2001; a formal update is currently underway.
Study Selection
Studies were included if they were randomized controlled trials or nonequivalent group designs with nonrandom allocation. The participants of the studies were qualified health professionals or health professionals in postgraduate training (eg, resident physicians). Studies involving only undergraduate students were excluded. All types of educational activities were included (eg, meeting, conferences, lectures, workshop, seminar), and interventions were didactic, interactive, or a mixed didactic and interactive nature. Didactic intervention offered minimal participant interaction such as lectures or presentations; interactive interventions included role play, case discussion, or hands-on training in small (<10 people), moderate (10 to 19 people), or large (>19 people) participant groups. Only the studies that objectively measured health professional practice behavior or patient outcomes in the setting in which health care was provided were included.
Data Extraction
Two authors independently applied inclusion criteria, assessed the quality of each study, and extracted the data. Each study was then assigned a quality rating of protection against bias according to 3 criteria: study design, blinded outcome assessment, and completeness of follow-up. Studies were analyzed according to the type of intervention, subjective assessment of complexity of targeted behaviors, and the level of baseline compliance and protection against bias.
Main Results
Educational Meeting Versus No Intervention
Of the 32 studies with 35 comparisons between educational meeting and noninterventional control groups, 24 studies reported marked improvement in professional practice. There were statistically significant ...
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.
This document discusses multisource feedback (MSF) and its use in physician assessment and revalidation. It provides evidence from various studies that MSF can reliably and validly assess physician competencies. However, it also notes limitations in terms of its ability to consistently change physician behavior and the high costs associated with MSF programs. Overall, the document presents both sides of the debate around using MSF as an essential component of physician revalidation.
The document describes two studies that developed and validated a Treatment Goals Checklist (TGC) to measure client treatment goals. Study 1 used exploratory factor analysis of responses from 131 adult clients to identify a five factor structure to the TGC: Positive Enhancement, Harming, Change, Use of drug, and Alcohol use. Study 2 confirmed the five factor structure using confirmatory factor analysis with 124 clients and found the five factor model was a better fit than competing models. The results support the TGC as a valid multidimensional measure of client treatment goals that can help counselors effectively assess and direct treatment.
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 outlines evidence-based best practices for reducing recidivism among chemically dependent clients. It discusses using motivational interviewing, pharmacological interventions like naltrexone, and drug avoidance skills training. Interviews with practitioners and clients at JADAC identified issues with frequent readmissions and a lack of consequences. Implementing motivational interviewing agency-wide and incorporating elements like drug avoidance training or naltrexone could help clients stay in treatment longer and reduce relapse rates.
This document outlines evidence-based practices for reducing recidivism among chemically dependent clients. It discusses conducting interviews with practitioners and clients at JADAC to identify issues with the current treatment approach. Research findings suggest implementing motivational interviewing, pharmacological interventions like naltrexone, and drug avoidance skills training to improve outcomes. The goal is for clients to stay in treatment longer and relapse less frequently after discharge.
This study investigated whether providing a document template for patients to describe their values and preferences to their physician improves shared decision making when deciding to start a new medication. The study found that the template did not significantly reduce decision conflict or regret, but did increase agreement between the physician's recommendation and the patient's final decision. It also increased the rate of patients carefully considering the physician's opinion rather than immediately agreeing or refusing. The template may enhance dialogue and encourage patients to consider their physician's professional advice.
This qualitative systematic review synthesized 77 papers reporting on 60 studies to understand patients' experiences of chronic non-malignant musculoskeletal pain. The key finding was that patients experience chronic pain as an adversarial struggle on multiple levels, including affirming their identity, reconstructing their identity over time, explaining their suffering, navigating the healthcare system, and proving the legitimacy of their pain. However, some patients also expressed a sense of moving forward alongside their pain. The review provides insight for improving the patient experience by better understanding their pain and forming collaborative partnerships to help patients manage their condition.
Partial and Incremental PCMH Practice Transformation: Implications for Qualit...Paul Grundy
Experience of BCBS Michigan in Building medical homes
Based on the observed relationships for partial implementation,full implementation of the PCMH model is associated with a 3.5 percent higher quality composite score, a 5.1 percent higher preventive composite score, and $26.37 lower per member per month medical costs for adults. Full PCMH implementation is also associated with a 12.2 percent higher preventive composite score, but no reductions in costs for pediatric populations. Incremental improvements in PCMH model implementation yielded similar positive effects on quality of care for both adult and pediatric populations but were not associated with cost savings for either population.
Conclusions. Estimated effects of the PCMH model on quality and cost of care
appear to improve with the degree of PCMH implementation achieved and with incremental improvements in implementation.
Summary of SAMHSA's review of and listing of feedback Informed Treatment as an evidence-based practice. The International Center for Clinical Excellence received perfect scores for readiness for dissemination materials
The study tested an electronic diabetes tracker shared between patients and providers to improve diabetes care. Patients in the intervention group had access to the tracker and decision support. They saw greater improvements in monitoring of diabetes factors and clinical outcomes like blood pressure and HbA1c levels compared to the control group. However, it is unclear if the improvements were due to the decision support, reminders, or more frequent provider visits in the intervention group.
The Carlat Psychiatry Report (Interview with Scott Miller, April 2015)Scott Miller
The April 2015 issue of the Carlat Psychiatry Report, an unbiased report/review of "all things psychiatric." The issue contains a lengthy interview with Dr. Scott Miller on the subject of top performing clinicians.
HCL Notes und Domino Lizenzkostenreduzierung in der Welt von DLAUpanagenda
Webinar Recording: https://www.panagenda.com/webinars/hcl-notes-und-domino-lizenzkostenreduzierung-in-der-welt-von-dlau/
DLAU und die Lizenzen nach dem CCB- und CCX-Modell sind für viele in der HCL-Community seit letztem Jahr ein heißes Thema. Als Notes- oder Domino-Kunde haben Sie vielleicht mit unerwartet hohen Benutzerzahlen und Lizenzgebühren zu kämpfen. Sie fragen sich vielleicht, wie diese neue Art der Lizenzierung funktioniert und welchen Nutzen sie Ihnen bringt. Vor allem wollen Sie sicherlich Ihr Budget einhalten und Kosten sparen, wo immer möglich. Das verstehen wir und wir möchten Ihnen dabei helfen!
Wir erklären Ihnen, wie Sie häufige Konfigurationsprobleme lösen können, die dazu führen können, dass mehr Benutzer gezählt werden als nötig, und wie Sie überflüssige oder ungenutzte Konten identifizieren und entfernen können, um Geld zu sparen. Es gibt auch einige Ansätze, die zu unnötigen Ausgaben führen können, z. B. wenn ein Personendokument anstelle eines Mail-Ins für geteilte Mailboxen verwendet wird. Wir zeigen Ihnen solche Fälle und deren Lösungen. Und natürlich erklären wir Ihnen das neue Lizenzmodell.
Nehmen Sie an diesem Webinar teil, bei dem HCL-Ambassador Marc Thomas und Gastredner Franz Walder Ihnen diese neue Welt näherbringen. Es vermittelt Ihnen die Tools und das Know-how, um den Überblick zu bewahren. Sie werden in der Lage sein, Ihre Kosten durch eine optimierte Domino-Konfiguration zu reduzieren und auch in Zukunft gering zu halten.
Diese Themen werden behandelt
- Reduzierung der Lizenzkosten durch Auffinden und Beheben von Fehlkonfigurationen und überflüssigen Konten
- Wie funktionieren CCB- und CCX-Lizenzen wirklich?
- Verstehen des DLAU-Tools und wie man es am besten nutzt
- Tipps für häufige Problembereiche, wie z. B. Team-Postfächer, Funktions-/Testbenutzer usw.
- Praxisbeispiele und Best Practices zum sofortigen Umsetzen
Ocean lotus Threat actors project by John Sitima 2024 (1).pptxSitimaJohn
Ocean Lotus cyber threat actors represent a sophisticated, persistent, and politically motivated group that poses a significant risk to organizations and individuals in the Southeast Asian region. Their continuous evolution and adaptability underscore the need for robust cybersecurity measures and international cooperation to identify and mitigate the threats posed by such advanced persistent threat groups.
Cosa hanno in comune un mattoncino Lego e la backdoor XZ?Speck&Tech
ABSTRACT: A prima vista, un mattoncino Lego e la backdoor XZ potrebbero avere in comune il fatto di essere entrambi blocchi di costruzione, o dipendenze di progetti creativi e software. La realtà è che un mattoncino Lego e il caso della backdoor XZ hanno molto di più di tutto ciò in comune.
Partecipate alla presentazione per immergervi in una storia di interoperabilità, standard e formati aperti, per poi discutere del ruolo importante che i contributori hanno in una comunità open source sostenibile.
BIO: Sostenitrice del software libero e dei formati standard e aperti. È stata un membro attivo dei progetti Fedora e openSUSE e ha co-fondato l'Associazione LibreItalia dove è stata coinvolta in diversi eventi, migrazioni e formazione relativi a LibreOffice. In precedenza ha lavorato a migrazioni e corsi di formazione su LibreOffice per diverse amministrazioni pubbliche e privati. Da gennaio 2020 lavora in SUSE come Software Release Engineer per Uyuni e SUSE Manager e quando non segue la sua passione per i computer e per Geeko coltiva la sua curiosità per l'astronomia (da cui deriva il suo nickname deneb_alpha).
Monitoring and Managing Anomaly Detection on OpenShift.pdfTosin Akinosho
Monitoring and Managing Anomaly Detection on OpenShift
Overview
Dive into the world of anomaly detection on edge devices with our comprehensive hands-on tutorial. This SlideShare presentation will guide you through the entire process, from data collection and model training to edge deployment and real-time monitoring. Perfect for those looking to implement robust anomaly detection systems on resource-constrained IoT/edge devices.
Key Topics Covered
1. Introduction to Anomaly Detection
- Understand the fundamentals of anomaly detection and its importance in identifying unusual behavior or failures in systems.
2. Understanding Edge (IoT)
- Learn about edge computing and IoT, and how they enable real-time data processing and decision-making at the source.
3. What is ArgoCD?
- Discover ArgoCD, a declarative, GitOps continuous delivery tool for Kubernetes, and its role in deploying applications on edge devices.
4. Deployment Using ArgoCD for Edge Devices
- Step-by-step guide on deploying anomaly detection models on edge devices using ArgoCD.
5. Introduction to Apache Kafka and S3
- Explore Apache Kafka for real-time data streaming and Amazon S3 for scalable storage solutions.
6. Viewing Kafka Messages in the Data Lake
- Learn how to view and analyze Kafka messages stored in a data lake for better insights.
7. What is Prometheus?
- Get to know Prometheus, an open-source monitoring and alerting toolkit, and its application in monitoring edge devices.
8. Monitoring Application Metrics with Prometheus
- Detailed instructions on setting up Prometheus to monitor the performance and health of your anomaly detection system.
9. What is Camel K?
- Introduction to Camel K, a lightweight integration framework built on Apache Camel, designed for Kubernetes.
10. Configuring Camel K Integrations for Data Pipelines
- Learn how to configure Camel K for seamless data pipeline integrations in your anomaly detection workflow.
11. What is a Jupyter Notebook?
- Overview of Jupyter Notebooks, an open-source web application for creating and sharing documents with live code, equations, visualizations, and narrative text.
12. Jupyter Notebooks with Code Examples
- Hands-on examples and code snippets in Jupyter Notebooks to help you implement and test anomaly detection models.
Fueling AI with Great Data with Airbyte WebinarZilliz
This talk will focus on how to collect data from a variety of sources, leveraging this data for RAG and other GenAI use cases, and finally charting your course to productionalization.
Ivanti’s Patch Tuesday breakdown goes beyond patching your applications and brings you the intelligence and guidance needed to prioritize where to focus your attention first. Catch early analysis on our Ivanti blog, then join industry expert Chris Goettl for the Patch Tuesday Webinar Event. There we’ll do a deep dive into each of the bulletins and give guidance on the risks associated with the newly-identified vulnerabilities.
How to Get CNIC Information System with Paksim Ga.pptxdanishmna97
Pakdata Cf is a groundbreaking system designed to streamline and facilitate access to CNIC information. This innovative platform leverages advanced technology to provide users with efficient and secure access to their CNIC details.
Digital Marketing Trends in 2024 | Guide for Staying AheadWask
https://www.wask.co/ebooks/digital-marketing-trends-in-2024
Feeling lost in the digital marketing whirlwind of 2024? Technology is changing, consumer habits are evolving, and staying ahead of the curve feels like a never-ending pursuit. This e-book is your compass. Dive into actionable insights to handle the complexities of modern marketing. From hyper-personalization to the power of user-generated content, learn how to build long-term relationships with your audience and unlock the secrets to success in the ever-shifting digital landscape.
Driving Business Innovation: Latest Generative AI Advancements & Success StorySafe Software
Are you ready to revolutionize how you handle data? Join us for a webinar where we’ll bring you up to speed with the latest advancements in Generative AI technology and discover how leveraging FME with tools from giants like Google Gemini, Amazon, and Microsoft OpenAI can supercharge your workflow efficiency.
During the hour, we’ll take you through:
Guest Speaker Segment with Hannah Barrington: Dive into the world of dynamic real estate marketing with Hannah, the Marketing Manager at Workspace Group. Hear firsthand how their team generates engaging descriptions for thousands of office units by integrating diverse data sources—from PDF floorplans to web pages—using FME transformers, like OpenAIVisionConnector and AnthropicVisionConnector. This use case will show you how GenAI can streamline content creation for marketing across the board.
Ollama Use Case: Learn how Scenario Specialist Dmitri Bagh has utilized Ollama within FME to input data, create custom models, and enhance security protocols. This segment will include demos to illustrate the full capabilities of FME in AI-driven processes.
Custom AI Models: Discover how to leverage FME to build personalized AI models using your data. Whether it’s populating a model with local data for added security or integrating public AI tools, find out how FME facilitates a versatile and secure approach to AI.
We’ll wrap up with a live Q&A session where you can engage with our experts on your specific use cases, and learn more about optimizing your data workflows with AI.
This webinar is ideal for professionals seeking to harness the power of AI within their data management systems while ensuring high levels of customization and security. Whether you're a novice or an expert, gain actionable insights and strategies to elevate your data processes. Join us to see how FME and AI can revolutionize how you work with data!
Programming Foundation Models with DSPy - Meetup SlidesZilliz
Prompting language models is hard, while programming language models is easy. In this talk, I will discuss the state-of-the-art framework DSPy for programming foundation models with its powerful optimizers and runtime constraint system.
Generating privacy-protected synthetic data using Secludy and MilvusZilliz
During this demo, the founders of Secludy will demonstrate how their system utilizes Milvus to store and manipulate embeddings for generating privacy-protected synthetic data. Their approach not only maintains the confidentiality of the original data but also enhances the utility and scalability of LLMs under privacy constraints. Attendees, including machine learning engineers, data scientists, and data managers, will witness first-hand how Secludy's integration with Milvus empowers organizations to harness the power of LLMs securely and efficiently.
UiPath Test Automation using UiPath Test Suite series, part 6DianaGray10
Welcome to UiPath Test Automation using UiPath Test Suite series part 6. In this session, we will cover Test Automation with generative AI and Open AI.
UiPath Test Automation with generative AI and Open AI webinar offers an in-depth exploration of leveraging cutting-edge technologies for test automation within the UiPath platform. Attendees will delve into the integration of generative AI, a test automation solution, with Open AI advanced natural language processing capabilities.
Throughout the session, participants will discover how this synergy empowers testers to automate repetitive tasks, enhance testing accuracy, and expedite the software testing life cycle. Topics covered include the seamless integration process, practical use cases, and the benefits of harnessing AI-driven automation for UiPath testing initiatives. By attending this webinar, testers, and automation professionals can gain valuable insights into harnessing the power of AI to optimize their test automation workflows within the UiPath ecosystem, ultimately driving efficiency and quality in software development processes.
What will you get from this session?
1. Insights into integrating generative AI.
2. Understanding how this integration enhances test automation within the UiPath platform
3. Practical demonstrations
4. Exploration of real-world use cases illustrating the benefits of AI-driven test automation for UiPath
Topics covered:
What is generative AI
Test Automation with generative AI and Open AI.
UiPath integration with generative AI
Speaker:
Deepak Rai, Automation Practice Lead, Boundaryless Group and UiPath MVP
For the full video of this presentation, please visit: https://www.edge-ai-vision.com/2024/06/building-and-scaling-ai-applications-with-the-nx-ai-manager-a-presentation-from-network-optix/
Robin van Emden, Senior Director of Data Science at Network Optix, presents the “Building and Scaling AI Applications with the Nx AI Manager,” tutorial at the May 2024 Embedded Vision Summit.
In this presentation, van Emden covers the basics of scaling edge AI solutions using the Nx tool kit. He emphasizes the process of developing AI models and deploying them globally. He also showcases the conversion of AI models and the creation of effective edge AI pipelines, with a focus on pre-processing, model conversion, selecting the appropriate inference engine for the target hardware and post-processing.
van Emden shows how Nx can simplify the developer’s life and facilitate a rapid transition from concept to production-ready applications.He provides valuable insights into developing scalable and efficient edge AI solutions, with a strong focus on practical implementation.
Salesforce Integration for Bonterra Impact Management (fka Social Solutions A...Jeffrey Haguewood
Sidekick Solutions uses Bonterra Impact Management (fka Social Solutions Apricot) and automation solutions to integrate data for business workflows.
We believe integration and automation are essential to user experience and the promise of efficient work through technology. Automation is the critical ingredient to realizing that full vision. We develop integration products and services for Bonterra Case Management software to support the deployment of automations for a variety of use cases.
This video focuses on integration of Salesforce with Bonterra Impact Management.
Interested in deploying an integration with Salesforce for Bonterra Impact Management? Contact us at sales@sidekicksolutionsllc.com to discuss next steps.
2. 94 DUNCAN
Lambert, Harmon, Smart, & Bailey, 2008; Whipple et al., 2003). recovery, social justice, and the needs of the front-line clinician is
When the odds of deterioration and clinically significant improve- discussed.
ment were compared, those in the feedback group had less than
half the odds of experiencing deterioration while having approxi- PCOMS: Measure Development and Validation
mately 2.6 times higher odds of attaining reliable improvement
than the treatment as usual (TAU) group. Scott Miller and I started using the OQ (Lambert et al., 1996)
All six trials realised significant gains for feedback groups over not long after its development in our practices as well as in
TAU for at-risk clients. Three of the six studies suggested that consultation with mental health agencies (see Duncan & Miller,
feedback enhances outcome for clients who are at risk but yield 2000). I also supervised graduate students in a community clinic
little impact for other clients (Lambert, 2010). Three studies and used the OQ there as well. Despite its obvious strengths, many
(Harmon et al., 2007; Hawkins et al., 2004; Slade et al., 2008) clinicians complained about the length of time needed to complete
found that using continuous assessment was helpful to all clients, the measure and that it did not seem to fit many of the concerns
although those who were predicted to not succeed in treatment that clients brought to therapy. It became apparent that in spite of
benefited more. Whipple et al. (2003), Harmon et al. (2007), and the quality of the measure, the benefits of outcome monitoring
Slade et al. (2008) found that adding measures of the alliance, would not occur if therapists didn’t use it.
motivation to change, and perceived social support for clients Measure development, therefore, arose from the practical need
identified as not on track demonstrated incremental effectiveness to make a clinician friendly instrument. The ORS emerged from
over the continuous feedback model alone. Two studies looked at two ideas. First was scaling questions commonly used in solution
whether providing feedback to both therapist and client influences focused therapy to assess client perceptions of problems and goal
effectiveness. Hawkins et al. (2004) found that giving feedback on attainment (“On a scale of 0 to 10, with 0 being the worst it’s been
progress to both clients and therapists was associated with signif- with this concern and 10 being where you want it to be, where are
icant gains in outcome. However, Harmon et al. (2007) failed to things right now?”; Berg & deShazer, 1993). Client-based scaling
replicate these results. In total, this research makes a strong case provides instant feedback and privileges the client’s voice when
for routine measurement of outcome in everyday clinical practice assessing the effectiveness of therapy (Franklin, Corcoran,
(Lambert, 2010). Nowicki, & Streeter, 1997). After repeated occurrences of thera-
The other RCT supported method of using continuous client pist nonadherence to outcome measurement protocols (see Miller,
feedback to improve outcomes is the Partners for Change Outcome Duncan, Brown, Sparks, & Claud, 2003), I suggested to Miller that
Management System (PCOMS; Duncan, 2010, 2011; Duncan, we simply ask scaling questions based on the major domains from
Miller, & Sparks, 2004; Duncan & Sparks, 2002, 2010; Miller, the OQ to enable a total outcome score.
Duncan, Sorrell, & Brown, 2005). Much of this system’s appeal Later, after researching different formats, Miller suggested the
rests on the brevity of the measures and therefore its feasibility for use of a visual analog scale because of its demonstrated face
everyday use in the demanding schedules of front-line clinicians. validity instead of scaling questions, and the ORS (Miller &
The Outcome Rating Scale (ORS) and the Session Rating Scale Duncan, 2000) was born. Thereafter, based in two years of inde-
(SRS) are both four-item measures that track outcome and the pendent practice experience as well as the multiple teams that I
therapeutic alliance, respectively. PCOMS was based on Lambert supervised in the community clinic, the clinical process of using
et al.’s (1996) continuous assessment model using the OQ, but the ORS was detailed in Duncan and Sparks (2002) and further
there are differences beyond the measures. First, PCOMS is inte- articulated in Duncan et al., 2004 and Duncan, 2010. Later, it
grated into the ongoing psychotherapy process and includes a became evident that families would be unable to participate in
transparent discussion of the feedback with the client (Duncan, feedback protocols without a valid measure for children. With this
2010; Duncan & Sparks, 2002). Session by session interaction is as an impetus, the Child Outcome Rating Scale (CORS; Duncan,
focused by client feedback about the benefits or lack thereof of Miller, & Sparks, 2003a) was developed. (All the measures dis-
psychotherapy. Second, PCOMS assesses the therapeutic alliance cussed here are available for free download for individual use at
every session and includes a discussion of any potential problems. www.heartandsoulofchange.com).
Lambert’s system includes alliance assessment only when there is The ORS assesses four dimensions: (1) Individual—personal or
a lack of progress. Moreover, unlike most other outcome instru- symptomatic distress or well being, (2) Interpersonal—relational
ments, the ORS is not a list of symptoms or problems checked by distress or how well the client is getting along in intimate rela-
clients or others on a Likert Scale. Rather it is an instrument that tionships, (3) Social—the client’s view of satisfaction with work/
evolves from a general framework of client distress to a specific school and relationships outside of the home, and (4) Overall—a
representation of the client’s idiosyncratic experience and reasons big picture view or general sense of well-being. The ORS trans-
for service. It therefore requires collaboration with clients as well lates these four dimensions into a visual analog format of four
as clinical nuance in its application. 10-cm lines, with instructions to place a mark on each line with
This article chronicles the development of PCOMS from its low estimates to the left and high to the right. The four 10-cm lines
beginnings as a simple way to discuss the benefit of services with add to a total score of 40. The score is the summation of the marks
clients to its emergence as an evidenced based practice to improve made by the client to the nearest millimeter on each of the four
psychotherapy outcomes. The research supporting the psychomet- lines, measured by a centimeter ruler or template. Because of its
rics of the measures and the PCOMS intervention is presented and simplicity, ORS feedback is immediately available for use at the
the clinical process summarised. Finally, examples of successful time the service is delivered. Rated at a seventh-grade reading
transportation of PCOMS to public behavioural health are offered level and translated into multiple languages, the ORS is easily
and an implementation process that values consumer involvement, understood by adults and adolescents from a variety of different
3. PARTNERS FOR CHANGE OUTCOME MANAGEMENT SYSTEM 95
cultures and enjoys rapid connection to clients’ day-to-day lived The SRS simply translates what is known about the alliance into
experience. four visual analog scales, based in Bordin’s (1979) classic delin-
On par with its clinical usefulness, the utility of the ORS and its eation of the components of the alliance: the relational bond and
ultimate transportability depends on the reliability and validity of the degree of agreement between the client and therapist about the
its scores. In addition to the ORS/SRS manual (Duncan, 2011; goals and tasks of therapy. First, a relationship scale rates the
Miller & Duncan, 2004), four validation studies of the ORS have meeting on a continuum from “I did not feel heard, understood,
been published (Bringhurst, Watson, Miller, & Duncan, 2006; and respected” to “I felt heard, understood, and respected.” Second
Campbell & Hemsley, 2009; Duncan, Sparks, Miller, Bohanske, & is a goals and topics scale that rates the conversation on a contin-
Claud, 2006; Miller et al., 2003). Across studies, average uum from “We did not work on or talk about what I wanted to
Cronbach’s alpha coefficients for ORS scores were .85 (clinical work on or talk about” to “We worked on or talked about what I
samples) and .95 (nonclinical samples) (Gillaspy & Murphy, wanted to work on or talk about.” Third is an approach or method
2011). Duncan et al. (2006) reported that internal consistency for scale requiring the client to rate the meeting on a continuum from
the CORS was .93 for adolescents and .84 for children. As an “The approach is not a good fit for me” to “The approach is a good
indicator of treatment progress, ORS/CORS scores have been fit for me.” Finally, the fourth scale looks at how the client
found to be sensitive to change for clinical samples yet stable over perceives the encounter in total along the continuum: “There was
time for nonclinical samples (Bringhurst et al., 2006; Duncan et something missing in the session today” to “Overall, today’s
al., 2006; Miller et al., 2003). Statistically significant differences session was right for me.” Like the ORS, the instrument takes only
between pretreatment and posttreatment ORS scores support the a couple of minutes to administer, score, and discuss. The SRS is
ORS’s sensitivity to change (Duncan et al., 2006; Miller et al., scored similarly to the ORS, by adding the total of the client’s
2003). marks on the four 10-cm lines.
The concurrent validity of ORS scores has primarily been ex- A factor analysis by Hatcher and Barends (1996) revealed that
amined through correlations with established outcome measures. in addition to the general factor measured by all alliance scales
The average bivariate correlation between the ORS and OQ across (i.e., strength of the alliance), two other factors were predictive:
three studies (Bringhurst et al., 2006; Campbell & Hemsley, 2009; confident collaboration and the expression of negative feelings.
Miller et al., 2003) was .62 (range ϭ .53–.74), indicating moder-
Confident collaboration speaks to the level of confidence that the
ately strong concurrent validity (Gillaspy & Murphy, 2011).
client has that therapy and the therapist will be helpful. Although
Campbell and Hemsley (2009) reported moderately strong rela-
overlapping with question three on the SRS, the fourth scale of the
tionships (.53 to .74) between the ORS and the Depression Anxiety
SRS directly addresses this factor. The other factor predictive
Stress Scale (Lovibond & Lovibond, 1995), Quality of Life Scale
beyond the general strength of the alliance is the client’s freedom
(Burckhardt & Anderson, 2003), and Rosenberg Self-Esteem Scale
to voice negative feelings and reactions to the therapist. Clients
(Rosenberg, 1989). Duncan et al. (2006) found that the CORS also
who express even low levels of disagreement with their therapists
demonstrated moderate concurrent validity with the Youth Out-
report better progress (Hatcher & Barends, 1996). The entire SRS
come Questionnaire (YOQ; Burlingame et al., 2001) for adoles-
is based on encouraging clients to identify alliance problems, to
cents (r ϭ .53) and children (r ϭ .43). In addition, Miller et al.
elicit client disagreements about the therapeutic process so that the
(2003) reported that pretreatment ORS scores distinguished clini-
cal and nonclinical samples, providing further support for the clinician may change to better fit client expectations.
validity of ORS scores. Like most outcome instruments, the ORS For SRS scores, internal consistency estimates were reported in
appears to measure global distress. four studies with an average alpha of .92, range .88 (Anker, Owen,
In the real world of delivering services, finding the right out- Duncan, & Sparks, 2010; Duncan et al., 2003; Reese et al., 2010)
come measure means striking a balance between the competing to .96 (Miller & Duncan, 2004) (Gillaspy & Murphy, 2011). These
demands of validity, reliability, and feasibility. The development alpha coefficients suggest that the SRS assesses a single, global
of the ORS and CORS reflects an attempt to find such a balance alliance construct. This is consistent with research on other alli-
(Duncan et al., 2006: Miller et al., 2003). ance measures such as the Working Alliance Inventory (WAI;
Horvath & Greenberg, 1989). Three studies (Miller & Duncan,
2004; Duncan et al., 2003; Reese et al., 2010) reported test–retest
The Session Rating Scale (SRS) reliability of SRS scores from the first to second session. The
Routine assessment of the alliance enables therapists to identify average reliability coefficient was .59 (range ϭ .54 –.64), indicat-
and correct potential problems before they exert a negative effect ing adequate stability (Gillaspy & Murphy, 2011).
on outcome or result in dropout (Sharf, Primavera, & Diener, Two studies have investigated the concurrent validity of SRS
2010). Recognising the much replicated findings regarding the scores. Duncan et al. (2003) reported a correlation of .48 between
alliance as well as the need for a brief clinical tool, we developed the SRS and the Helping Alliance Questionnaire (HAQ-II; Lubor-
the SRS (Miller, Duncan, & Johnson, 2002), the Child Session sky et al., 1996). Campbell and Hemsley (2009) found that SRS
Rating Scale (CSRS) (Duncan, Miller, & Sparks, 2003b), the scores correlated .58 with the WAI-S (Tracey & Kokotovic, 1989).
Relationship Rating Scale (RRS) for peer services and self help These findings indicate moderate concurrent validity with longer
(Duncan & Miller, 2004), the Group Session Rating Scale (GSRS; alliance measures. Finally, the predictive validity of the SRS was
Duncan & Miller, 2007), and the Group Child Session Rating Sale supported by Duncan et al. (2003). Early SRS scores (2nd or 3rd
(GCSRS; Duncan, Miller, Sparks, & Murphy, 2011) as brief session) were predictive of posttreatment ORS scores (r ϭ .27),
alternatives to longer research-based measures to encourage rou- which is consistent with previous research linking early client
tine conversations with clients about the alliance. perceptions of alliance with outcome (Horvath & Bedi, 2002).
4. 96 DUNCAN
Further support of both the feasibility and impact of monitoring These studies collectively support the effectiveness of PCOMS
the alliance is demonstrated in a large study (250 couples) of the across various treatment sites and models. The average effect size
alliance in couple therapy (Anker et al., 2010). The alliance sig- for PCOMS versus TAU was .52, representing a medium treatment
nificantly predicted outcome over and above early change, sug- effect. PCOMS is designated as an evidenced based treatment in
gesting that the alliance is not merely an artifact of client improve- Colorado and Arizona and is currently under review by the Sub-
ment. The study also found that those couples whose alliance stance Abuse Mental Health Services Administration (SAMHSA)
scores ascended attained significantly better outcomes than those for listing in the National Registry of Evidence-based Programs
whose alliances scores did not improve. Together these findings and Practices. Three more RCTs are in various stages of comple-
suggest that therapists should not leave the alliance to chance but tion.
rather routinely assess it with clients in each session.
The Clinical Process
PCOMS: The Research
PCOMS is a-theoretical and may be added to or integrated with
After development of the measures and the clinical process, and any model of practice. The clinical process of PCOMS boils down
validation of the instruments, it was time to see if PCOMS made to this: identifying clients who aren’t responding to clinician
a difference in outcomes. Four studies have demonstrated the business as usual and addressing the lack of progress in a positive,
benefits of client feedback with the ORS and SRS. Although two proactive way that keeps clients engaged while therapists collab-
of the studies focused on individual therapy (Miller, Duncan, oratively seek new directions. To retain clients at risk for slipping
Brown, Sorrell, & Chalk, 2006; Reese, Norsworthy, & Rowland, through the proverbial crack requires embracing what is known
2009), Anker, Duncan, and Sparks (2009) and Reese, Toland, about change in therapy. Time and again, from the pioneering
Slone, and Norsworthy (2010) extended evaluation of PCOMS to work of the late Ken Howard (Howard, Kopta, Krause, &
couples therapy. All studies evaluated treatment outcome based on Orlinsky, 1986) to current sophisticated investigations using the
reliable change or clinically significant change (Jacobson & Truax, latest statistical methods (Baldwin, Berkeljon, Atkins, Olsen, &
1991). Cohen’s d effect sizes were reported in all studies. Nielsen, 2009), studies reveal that the majority of clients experi-
The first (Miller et al., 2006) was a quasi-experimental, ABB ence the majority of change in the first six to eight visits. Clients
design; the other three were between-subjects, RCTs. Miller et al. who report little or no progress early on will likely show no
(2006) explored the impact of feedback in a large (n ϭ 6424) improvement over the entire course of therapy, or will end up on
culturally diverse sample utilizing a telephonic EAP. Although the the drop-out list— early change predicts engagement in therapy
study’s quasi-experimental design qualifies the results, the use of and a good outcome at termination (Brown, Dreis, & Nace, 1999).
outcome feedback doubled overall effectiveness (ES at baseline ϭ Some clients do take longer, but importantly not for change to
.37; follow-up ϭ .79) and significantly increased retention. Three start, but rather for change to plateau (Baldwin et al., 2009).
RCTs used PCOMS to investigate the effects of feedback versus Monitoring change provides a tangible way to identify those who
TAU. Anker et al. (2009) randomized couples seeking couples are not responding so that a new course can be charted.
therapy (n ϭ 410) to PCOMS or TAU; therapists served as their A second robust predictor of change solidly demonstrated by a
own controls. This study, the largest RCT of couple therapy ever large body of studies (Norcross, 2010), is that tried and true but
done, found that feedback clients reached clinically significant taken for granted old friend, the therapeutic alliance. Clients who
change nearly four times more than nonfeedback couples, and over highly rate their partnership with their therapists are more apt to
doubled the percentage of couples in which both individuals remain in therapy and benefit from it.
reached reliable and/or clinically significant change (50.5% vs. Exhibit 1 delineates the 12 therapist competencies/skills re-
22.6%). At 6-month follow-up, 47.6% of couples in the feedback quired for implementation. Given that at its heart, PCOMS is a
condition reported reliable and/or significant change versus 18.8% collaborative intervention, everything about the use of the mea-
in TAU (ES ϭ.50 after treatment, .44 at follow-up). The feedback sures and the results attained are shared with clients. Conse-
condition maintained its advantage at 6-month follow-up and quently, the client needs to understand two points: that the ORS
achieved a 46% lower separation/divorce rate. Feedback improved will be used to collaboratively track outcome in every session and
the outcomes of nine of 10 therapists in this study. that it is a way to make sure that the client’s voice is not only heard
In an independent investigation, Reese et al. (2009) found but remains central.
significant treatment gains for feedback when compared to TAU. The ORS is given at the beginning of each session. In the first
This study was two small trials in one. Study 1 occurred at a meeting, the ORS pinpoints where the client sees him or herself,
university counselling centre (n ϭ 74) and Study 2 at a graduate allowing for an ongoing comparison in later sessions. The ORS is
training clinic (n ϭ 74). Clients in the PCOMS condition in both not an assessment tool in the traditional sense. Rather it is a clinical
studies showed more change versus TAU clients (80% vs. 54% in tool intimately integrated into the work itself. It requires that the
Study 1, 67% vs. 41% in Study 2; ES from .49 to .54). In addition, therapist ensure that the ORS represents both the client’s experi-
clients in PCOMS achieved reliable change in significantly fewer ence and the reasons for service—that the general framework of
sessions than TAU. The last RCT (Reese et al., 2010) replicated client distress evolves into a specific account of the work done in
the Anker et al. study with couples and found nearly the same therapy. Clients usually mark the scale the lowest that represents
results. Finally, a recent meta-analysis of PCOMS studies the reason they are seeking therapy, and often connect that reason
(Lambert & Shimokawa, 2011) found that those in feedback group to the mark they’ve made without prompting from the therapist.
had 3.5 higher odds of experiencing reliable change and less than Other times, the therapist needs to clarify the connection between
half the odds of experiencing deterioration. the client’s descriptions of the reasons for services and the client’s
5. PARTNERS FOR CHANGE OUTCOME MANAGEMENT SYSTEM 97
marks on the ORS. This enables the therapist and the client to be administrations of the ORS) and provides suggestions for clients
on the “same page” regarding what the marks say about the and therapists to consider (Figure 1).
therapeutic work and whether the client is making any gains. At The progression of the conversation with clients who are not
the moment clients connect the marks on the ORS with the benefiting goes from talking about whether something different
situations that prompt their seeking help, the ORS becomes a should be done to identifying what differently can be done, to
meaningful measure of progress and a potent clinical tool. doing something different. Doing something different can take as
The SRS opens space for the client’s voice about the alliance. It many forms as there are clients: inviting others from the client’s
is given at the end of the meeting, but leaving enough time for support system, using a team or another professional, a different
discussing the client’s responses. The SRS is not a measure of conceptualisation of the problem or another treatment approach; or
competence or ultimate ability to form good alliances, or anything referring to another therapist or venue of service, religious advisor,
else negative about therapists or clients. It is about the fit of the or self-help group—whatever seems to be of value to the client.
service and any lower rating is an indication that the client feels
comfortable to report that something is wrong. Appreciation of any Implementation in Public Behavioural Health
negative feedback is a powerful alliance builder.
At second and subsequent sessions, interpretation of the ORS Although no experimental studies are available, several agencies
depends on both the amount and rate of change that has occurred have conducted systematic analyses of a variety of variables of
since the prior visit(s). The longer therapy continues without interest to the provision of services in public behavioural health.
measurable change, the greater the likelihood of drop out and/or (For a full discussion of implementation in public health settings,
poor outcome. The scores are used to engage the client in a see Bohanske & Franczak, 2010.) In the first study of agency
discussion about progress, and more importantly, what should be efficiency and PCOMS, Claud (2004; reported in Bohanske &
done differently if there isn’t any. Franczak, 2010), discussed how his agency, the Centre for Family
When ORS scores increase, a crucial step to empower the Services (CFS) in West Palm Beach, Florida, struggled to cope
change is to help clients see any gains as a consequence of their with limited resources, lengthy episodes of care, and high no show
own efforts. This requires an exploration of the clients’ perception and attrition rates. After implementing PCOMS, average length of
stay (LOS) decreased more than 40%, and cancellation and no-
of the relationship between their own efforts and the occurrence of
show rates dropped by 40 and 25%, respectively. Moreover, the
change (Duncan et al., 1992). When clients have reached a plateau
percentage of clients in long-term treatment that experienced little
or what may be the maximum benefit they will derive from
or no measured improvement fell by 80%. In one year, CFS saved
therapy, planning for community connection and continued recov-
nearly $500,000, funds that were used to hire additional staff and
ery outside of therapy can start. This could mean just reducing the
provide more services.
frequency of meetings and continuing to monitor the client’s goals.
Similarly, Community Health and Counselling Services in
For others, it could mean referral to self help groups or other
Bangor, Maine, experienced increases in the effectiveness and
community supports.
efficiency of services provided to clients characterised as “severely
A more important discussion occurs when ORS scores are not
and persistently mentally ill.” Over a three year period, no-show
increasing. The ORS gives clients a voice in all decisions that
and cancellation rates were reduced by 30% while the LOS de-
affect their care including whether continuation in therapy with the creased by 59%. At the same time, LOS in residential treatment
current provider is in their best interest. The ORS stimulates such and case management dropped by 50% and 72%, respectively,
a conversation so that both interested parties may struggle with the while consumer satisfaction with services markedly improved
implications of continuing a process that is yielding little or no (Haynes, 2006, reported in Bohanske & Franczak, 2010).
benefit. The intent is to support practices that are working and Finally, perhaps the largest single agency implementation to
challenge those that don’t appear to be helpful. Although ad- date is Southwest Behavioural Health Services (SBHS), a non-
dressed in each session in which it is apparent that no benefit is profit, behavioural health organisation in Arizona that employs
occurring, later ones gain increasing significance and warrant over 500 direct care staff with an annual budget of 36 million
additional action—what we have called the checkpoint conversa- dollars. SBHS implemented PCOMS in an effort to increase effi-
tions and last chance discussions (Duncan, 2010; Duncan & ciency and effectiveness as well as operationalize recovery prin-
Sparks, 2002). ciples (see below). Compared with adult clients who received
In a typical outpatient setting, checkpoint conversations are services before implementation (N ϭ 839), clients who received
conducted at the third to sixth session and last-chance discussions services including PCOMS (N ϭ 3420) had a 46% less LOS and
are initiated in the sixth to ninth meeting. This is simply saying that 50% fewer cancelled and no show appointments. At the same time,
the trajectories observed in most outpatient settings suggest that clinician evaluation of “full resolution” increased by 44% while
most clients who benefit from services usually show it in 3– 6 consumers rated themselves as achieving a reliable change in 52%
sessions; and if change is not noted by then, then the client is at a of the cases (Bohanske & Franczak, 2010).
risk for a negative outcome. The same goes for sessions six to nine Implementation of PCOMS in public health agencies is happen-
except that the urgency is increased, hence the term “last chance.” ing across the US (e.g., Bluegrass Regional Mental Health) and
Although not required to achieve the feedback effect, a web-based Canada (e.g., Saskatoon Health Region), as well as around the
system, MyOutcomes.com, provides a more sophisticated identi- globe: Norway (e.g., Bufetat), the United Kingdom (e.g., Lincoln-
fication of clients at risk. It graphs and compares the client’s shire Child and Adolescent Mental Health Services), and New
progress to the expected treatment response of clients with the Zealand (e.g., Wesley Community Action), to mention a few. Over
same intake score (the 50th percentile trajectory based on 300, 000 100,000 clients a year participate with PCOMS.
6. 98 DUNCAN
Figure 1. Screenshot of the electronic feedback system, MyOutcomes.com.
The Heart and Soul of Change Project pointed out that, “Successfully transforming the mental health
service delivery system rests on two principles” (NFCMH, 2003,
The Heart and Soul of Change Project (HSCP; www.heartand-
p. 4): First is:
soulofchange.com) is a practice-driven, training and research ini-
. . . a consumer- and family driven system, [where] consumers
tiative that focuses on improving outcomes via client based out-
choose their own programs and the providers that will help them
come feedback, the PCOMS intervention. The website is a major
most . . . Care is consumer-centered, with providers working in full
dissemination vehicle with over 150 free downloads (articles,
partnership with the consumers they serve to develop individual-
handouts, slide packages, videos, and webinars) on the use of the
ized plans of care (p. 28).
PCOMS feedback intervention. While PCOMS is not based in any
model-based assumptions and can be incorporated in any treat- Consumer involvement in all decisions that affect care also
ment, it does promote a set of service delivery values: client speaks to the issues of multiculturalism and social justice. Client-
privilege in determining the benefit of services as well as in all centered or directed care necessarily includes a recognition of the
decisions that affect care including intervention preferences; an disparate power that exists between the provider and consumer of
expectation of recovery; an attention to those common factors that services, especially for those not of the dominant culture as well as
cut across all models that account for therapeutic change; and an the traditionally disenfranchised, and transparently seeks to ad-
appreciation of social justice in the provision of care— or what is dress the disparity. Despite well-intentioned efforts, the infrastruc-
called client-directed, outcome-informed (CDOI) clinical work ture of therapy (paperwork, policies, procedures, and professional
(Duncan, 2010; Duncan et al., 2004; Duncan, Solovey, & Rusk, language) can reify noncontextualized descriptions of client prob-
1992; Duncan & Sparks, 2002, 2010). lems and silence client views, goals, and preferences.
Two of the above values have gained global traction and are In addition, the infrastructure of mental health itself (i.e., diag-
interwoven into HSCP implementation of PCOMS: consumer in- nosis and prescriptive treatment) often leaves little room for the
volvement and recovery-oriented services that tailor treatment to unique views of those whose culture, race, gender, gender expres-
the individual needs of the client. In the US, for example, the sion, ability, age, or socioeconomic status differ from typical
President’s New Freedom Commission (NFCMH; 2003) report providers steeped in mainstream psychology (Duncan et al., 2004;
7. PARTNERS FOR CHANGE OUTCOME MANAGEMENT SYSTEM 99
Sparks, 2012). Routinely requesting, documenting, and responding protocol. PCOMS is presented as the tie that binds these healing
to client feedback transforms power relations in the immediate components together, allowing the factors to be expressed one
therapy encounter by privileging client beliefs and goals over client at a time. Soliciting systematic feedback is a living, ongoing
culturally biased and insensitive practices. Outside the therapy process that engages clients in the collaborative monitoring of
dyad, client feedback protocols undermine inequities built into outcome, heightens hope for improvement, fits client preferences,
everyday mental health service delivery by redefining whose voice maximizes chances for a strong alliance, and is itself a core feature
counts. Use of client feedback applies the principles of social of therapeutic change (Duncan, 2010). An attention to common
justice that, until now, have largely existed only in the pages of factors also reflects the recommendations of the NCSMHR (see
training manuals, textbooks, and academic journals (Sparks, Exhibit 2).
2012). PCOMS seeks to level the psychotherapy process by invit- Although the over 300,000 administrations of the ORS/SRS has
ing collaborative decision making, honouring client diversity with yielded invaluable information regarding the psychometrics of the
multiple language availability, and valuing local cultural and con- measures, trajectories, algorithms, and so forth, PCOMS remains a
textual knowledge; PCOMS provides a mechanism for routine clinical intervention embedded in the complex interpersonal pro-
attention to multiculturalism and social justice. cess called psychotherapy. For successful implementation and
The second guiding principle of the NFCMH was that care ongoing adherence, PCOMS must appeal to therapists in ways that
needed to move away from treating illness and toward facilitating the numbers or data or even the research never can. Consequently,
and supporting recovery. A sharp departure from customary dis- PCOMS is described as the clinical process that it is— one that
course on mental illness, recovery-driven services shift away from requires skill and nuance to achieve the maximum feedback effect.
professional-directed treatment based on diagnostic labels and PCOMS speaks to therapists “where they live” by providing a
prescriptive practices to individually tailored, consumer-authored methodology to address those clients who do not benefit from their
plans. Shortly after the NFCMH report, with the participation of services.
consumers, advocates, family members, providers, academicians, Similarly, a focus on therapist development provides a positive
and researchers the “National Consensus Statement on Mental motivation for therapists to invest time and energy in PCOMS.
Health Recovery” (NCSMHR) was tendered: There will always be organisational motivations for PCOMS in
Mental health recovery is a journey of healing and transforma- terms of improved outcomes and reduced costs—the language of
tion enabling a person with a mental health problem to live a “return on investment” and “proof of value.” But there is also the
meaningful life in a community of his or her choice while striving personal motivation of the therapist, the very reason most got into
to achieve his or her full potential (National Consensus Statement this business in the first place: to make a difference in the lives of
on Mental Health Recovery, 2004, p. 1). those served. The groundbreaking research by Orlinsky and
Together with consumer directed services, the shift away from Rønnestad (2005) about therapist development (now over 11,000
illness toward recovery means that mental health professionals therapists included) demonstrates that nearly all therapists want to
must be both responsible and responsive to their customer base and continue to improve throughout their careers and harnessing this
directly involve clients in decision making. PCOMS is embedded motivation is part and parcel to successful implementation.
in the aims and philosophy of “recovery” as delineated by the PCOMS appeals to the best of therapist intentions and encourages
NCSMHC (see Exhibit 2) and provides a way to operationalize therapists to collect ORS data so that they can track their devel-
client driven, recovery-oriented services (Bohanske & Franczak, opment and implement strategies to improve their effectiveness
2010; Sparks & Munro, 2011). (Duncan, 2010).
Successful transportation of PCOMS to public behavioural Including these additional aspects allows therapists to see that
health requires organisational commitment at all levels (Exhibit 3 the intentions of PCOMS go well beyond management or funder’s
details a readiness checklist). Implementation also requires an cost or efficiency objectives— client based outcome feedback is
attention to front-line clinicians. For some who have been in the about client privilege and benefit, and helping therapists get better
field for a while, outcome management is a totally foreign concept at what they do. In addition, it is also critical that therapists know
while others have been turned off by cumbersome measures that that management only intends to use data to improve the quality of
seem far removed from their day-to-day work with clients. Still care that clients receive, that there will be no punitive use of the
others are fearful that “pay for performance” or similarly moti- data in any way, shape, or form. Given that most therapists
vated strategies will punish those who do not measure up to some improve their outcomes with feedback (recall that 9 of 10 thera-
arbitrary standard. Implementation is enhanced when it makes pists improved in the Anker et al. trial), a positive, noncompetitive
sense to therapists and appeals to their nearly universal desire to do approach goes a long way to assuage therapists’ fears.
good work. In an attempt to motivate practitioners to consider the After an initial 2-day training for all staff, implementation relies
benefits of feedback, the implementation process of the Heart and heavily on a “training of trainers” model, encouraging agencies to
Soul of Change Project also includes an attention to: (a) the build a core set of therapists, managers and/or supervisors to
common factors; (b) a nuanced clinical process; and (c) therapist provide ongoing training and supervision. Collecting data and
development. ongoing supervision are of primary importance to successful im-
The common factors, those elements of psychotherapy running plementation. The data tell all, allowing rapid information about
across all models that account for change (Duncan, 2010; Duncan not only who is using the measures but also whether the measures
et al., 2010), provide an overarching framework for the PCOMS are being used properly thus allowing data integrity. Data indica-
intervention. Integrating the use of PCOMS within the larger tors of correct and incorrect use are easily taught and integrated
literature about what works in therapy promotes therapist under- into the supervisory process allowing supervisors to monitor and
standing of the feedback process and adherence to the feedback build therapist skill level. A four step supervisory process (Duncan
8. 100 DUNCAN
& Sparks, 2010) that focuses first on ORS identified clients at risk, their careers. PCOMS calls for a more sophisticated and em-
and then on individual clinician effectiveness and how improve- pirically informed clinician who chooses from a variety of
ment can occur, strengthens the possibility of successful imple- orientations and methods to best fit client preferences and
mentation. cultural values. Although there has not been convincing evi-
dence for differential efficacy among approaches (Duncan et
Conclusions al., 2010), there is indeed differential effectiveness for the
client in the room now—therapists need expertise in a broad
However beautiful the strategy, you should occasionally look at the range of intervention options, including evidence based treat-
results. ments, but must remember that however beautiful the strategy,
—Sir Winston Churchill that one must occasionally look at results.
The time for client-based outcome feedback seems to have Exhibit 1. PCOMS Therapist Competency Checklist
arrived (Lambert, 2010). For example, the American Psychologi-
cal Association (APA) Presidential Task Force (hereafter Task 1. Administer and score the Outcome Rating Scale (ORS) each
Force) on Evidence-Based Practice in Psychology (EBPP) defined session or unit of service.
EBPP as “the integration of the best available research with 2. Ensure that the client understands that the ORS is intended to
clinical expertise in the context of patient (sic) characteristics, bring his or her voice into the decision-making process and will be
culture, and preferences” (American Psychological Association collaboratively used to monitor progress.
Presidential Task Force on Evidence-Based Practice, 2006, p. 3. Ensure that the client gives a good rating; that is, a rating that
273). Two parts of this definition draw attention to client feedback matches the client’s description of his or her life circumstance.
and to tailoring services to the individual client. First, regarding 4. Ensure that the client’s marks on the ORS are connected to
clinical expertise, the Task Force submitted: the described reasons for service.
Clinical expertise also entails the monitoring of patient progress 5. Use ORS data to develop and graph individualized trajecto-
. . . If progress is not proceeding adequately, the psychologist ries of change.
alters or addresses problematic aspects of the treatment (e.g., 6. Plot ORS on individualized trajectories from session to ses-
problems in the therapeutic relationship or in the implementation sion to determine which clients are making progress and which are
of the goals of the treatment) as appropriate. (American Psycho- at risk for a negative or null outcome.
logical Association Presidential Task Force on Evidence-Based 7. Use ORS scores to engage clients in a discussion in every
Practice, 2006, pp. 276 –277) session about how to continue to empower change if it is happen-
And second, “in the context of patient characteristics, culture, ing and change, augment, or end treatment if it is not.
and preferences,” emphasizes what the client brings to the thera- 8. Administer and score the Session Rating Scale (SRS) each
peutic stage as well as the acceptability of any intervention to the session or unit of service.
client’s expectations. The Task Force said: 9. Ensure that the client understands that the SRS is intended to
create a dialogue between therapist and client that more tailors the
The application of research evidence to a given patient always in- service to the client—and that there is no bad news on the measure.
volves probabilistic inferences. Therefore, ongoing monitoring of 10. Use the SRS to discuss whether the client feels heard,
patient progress and adjustment of treatment as needed are essential. understood, and respected.
(American Psychological Association Presidential Task Force on 11. Use the SRS to discuss whether the service is addressing the
Evidence-Based Practice, 2006, p. 280) client’s goals for treatment.
12. Use the SRS to discuss whether the service approach
Outcome, in other words, is not guaranteed regardless of evi- matches the client’s culture, preferences worldview, or theory of
dentiary support of a given technique or the expertise of the change.
therapist. Client-based outcome feedback must become routine.
Further support comes from APA’s Division 29 Task Force on Exhibit 2. National Consensus Statement on Mental
Empirically Supported Relationships who advised practitioners
Health Recovery
“. . . to routinely monitor patients’ responses to the therapy rela-
tionship and ongoing treatment.” (Ackerman et al., 2001, p. 496). Self-direction. Consumers lead, control, exercise choice
Finally, two other recent endorsements of outcome management over, and determine their own path of recovery by optimizing
by APA have emerged. First the American Psychological Associ- autonomy, independence, and control of resources to achieve a
ation Commission on Accreditation (2011) states that students and self-determined life. By definition, the recovery process must
interns: “Be provided with supervised experience in collecting be self-directed by the individual, who defines his or her own
quantitative outcome data on the psychological services they pro- life goals and designs a unique path toward those goals.
vide . . .”(2011, C-24). And second, APA recently created a new Individualized and person-centered. There are multiple
outcome measurement database to encourage practitioners to se- pathways to recovery based on an individual’s unique strengths
lect outcome measures for practice (http://practiceoutcomes and resiliencies as well as his or her needs, preferences, expe-
.apa.org). riences (including past trauma), and cultural background in all
PCOMS provides a way to transport research to everyday of its diverse representations. Individuals also identify recovery
clinical practice. It also is a vehicle to operationalize a recovery as being an ongoing journey and an end result as well as an
and consumer-driven philosophy, and encourage providers to overall paradigm for achieving wellness and optimal mental
follow their natural proclivities to improve over the course of health.
9. PARTNERS FOR CHANGE OUTCOME MANAGEMENT SYSTEM 101
Empowerment. Consumers have the authority to choose uals with mental disabilities can make, ultimately becoming a
from a range of options and to participate in all decisions— stronger and healthier nation.
including the allocation of resources—that will affect their lives,
and are educated and supported in so doing. They have the ability
to join with other consumers to collectively and effectively speak
Exhibit 3. PCOMS Organisational Readiness Checklist
for themselves about their needs, wants, desires, and aspirations. 1. The Agency/Organisation/Behavioural Health Care
Through empowerment, an individual gains control of his or her System (hereafter agency) has secured Board of Direc-
own destiny and influences the organisational and societal struc- tor approval and support for PCOMS.
tures in his or her life.
Holistic. Recovery encompasses an individual’s whole life, 2. The agency has consensus among the agency director
including mind, body, spirit, and community. Recovery embraces and senior managers that consumer partnership, ac-
all aspects of life, including housing, employment, education, countability, and PCOMS are central features of service
mental health and health care treatment and services, complemen- delivery.
tary and naturalistic services, addictions treatment, spirituality,
creativity, social networks, community participation, and family 3. The agency has a business/financial plan that incorpo-
supports as determined by the person. Families, providers, organi- rates PCOMS.
sations, systems, communities, and society play crucial roles in
creating and maintaining meaningful opportunities for consumer 4. The agency infrastructure promotes regular communi-
access to these supports. cation with funders about PCOMS data as it applies to
Nonlinear. Recovery is not a step-by-step process but one agency effectiveness and efficiency.
based on continual growth, occasional setbacks, and learning from
experience. Recovery begins with an initial stage of awareness in 5. The agency has a human resource training and devel-
which a person recognizes that positive change is possible. This opment plan that supports ongoing PCOMS education
awareness enables the consumer to move on to fully engage in the of staff at all levels, and that intends to integrate
work of recovery. PCOMS into individual development plans, perfor-
Strengths-based. Recovery focuses on valuing and building mance appraisals, and hiring practices.
on the multiple capacities, resiliencies, talents, coping abilities,
6. The agency has the infrastructure (support staff, IT,
and inherent worth of individuals. By building on these strengths,
computer hardware, etc.) to support the collection and
consumers leave stymied life roles behind and engage in new life
analysis of PCOMS data at the individual consumer,
roles (e.g., partner, caregiver, friend, student, employee). The
therapist, program, and agency levels.
process of recovery moves forward through interaction with others
in supportive, trust-based relationships. 7. The agency has a supervisory infrastructure that allows
Peer support. Mutual support—including the sharing of ex- PCOMS data to be used to individualize treatment plan-
periential knowledge and skills and social learning—plays an ning, identify at risk clients and proactively address
invaluable role in recovery. Consumers encourage and engage treatment needs, and monitor/improve therapist perfor-
other consumers in recovery and provide each other with a sense mance.
of belonging, supportive relationships, valued roles, and commu-
nity. 8. The agency has a structure for and policy addressing
Respect. Community, systems, and societal acceptance and clients who are not progressing that insures rapid trans-
appreciation of consumers —including protecting their rights and fer and continuity of care.
eliminating discrimination and stigma—are crucial in achieving
recovery. Self-acceptance and regaining belief in one’s self are 9. The Mission Statement incorporates consumer partner-
particularly vital. Respect ensures the inclusion and full participa- ship and accountability as central features of service
tion of consumers in all aspects of their lives. delivery.
Responsibility. Consumers have a personal responsibility for
their own self-care and journeys of recovery. Taking steps toward 10. “Client Rights and Responsibilities” include the impor-
their goals may require great courage. Consumers must strive to tance of consumer feedback and partnership to guide
understand and give meaning to their experiences and identify treatment planning.
coping strategies and healing processes to promote their own
wellness.
Resume
´ ´
Hope. Recovery provides the essential and motivating mes-
sage of a better future— that people can and do overcome the Deux modeles de surveillance et de retroaction en continu revelent
` ´ ´ `
barriers and obstacles that confront them. Hope is internalized; but des gains dans le cadre d’essais cliniques aleatoires (ECA) : le
´
can be fostered by peers, families, friends, providers, and others. Outcome Questionnaire (OQ) System, de Lambert, et le Partners
Hope is the catalyst of the recovery process. Mental health recov- for Change Outcome Management System (PCOMS). L’article
ery not only benefits individuals with mental health disabilities by rappelle l’evolution du PCOMS, depuis une facon simple de dis-
´ ¸
focusing on their abilities to live, work, learn, and fully participate cuter des avantages des services avec les clients jusqu’a son`
in our society, but also enriches the texture of American commu- emergence comme pratique factuelle pour l’amelioration des re-
´ ´ ´
nity life. America reaps the benefits of the contributions individ- sultats. Quoiqu’il s’inspire du modele de Lambert, on y decele des
` ´ `
10. 102 DUNCAN
differences : le PCOMS est integre au processus de psychotherapie
´ ´ ´ ´ The reliability and validity of the Outcome Rating Scale: A replication
en cours et inclut une discussion transparente de la retroaction avec
´ study of a brief clinical measure. Journal of Brief Therapy, 5, 23–30.
le client; il evalue l’alliance a chaque rencontre; l’echelle Outcome
´ ` ´ Brown, J., Dreis, S., & Nace, D. (1999). What really makes a difference in
Rating Scale, plutot qu’une liste de symptomes evalues sur une
ˆ ˆ ´ ´ psychotherapy outcomes? Why does managed care want to know? In M.
e chelle Likert, est a la fois un outil et un instrument
´ ` Hubble, B. Duncan, & S. Miller (Eds.), The heart and soul of change
(pp. 389 – 406). Washington, DC: American Psychological Association.
d’aboutissement requerant la collaboration du client. L’article
´
Burckhardt, C., & Anderson, K. (2003). The Quality of Life Scale (QOLS):
presente la recherche a l’appui des caracteristiques psychome-
´ ` ´ ´
Reliability, validity, and utilization. Health and Quality of Life Out-
triques des mesures ainsi que l’intervention du PCOMS, suivies comes, 1, 60. doi:10.1186/1477-7525-1-60
d’un sommaire du processus clinique. Des exemples de la trans- Burlingame, G. M., Mosier, J. I., Wells, M. G., Atkin, Q. G., Lambert,
position reussie a la sante comportementale sont offerts. On y
´ ` ´ M. J., Whoolery, M., & Latkowski, M. (2001). Tracking the influence of
decrit ensuite le processus de mise en vigueur qui favorise la
´ mental health treatment: The development of the Youth Outcome Ques-
participation du client, le retablissement et la justice sociale, et les
´ tionnaire. Clinical Psychology and Psychotherapy, 8, 361–379.
besoins du clinicien de premiere ligne sont discutes. Forte de neuf
` ´ Campbell, A., & Hemsley, S. (2009). Outcome Rating Scale and Session
ECA et de l’appui de l’American Psychological Association, la Rating Scale in psychological practice: Clinical utility of ultra-brief
retroaction du client sur les resultats offre une facon pragmatique
´ ´ ¸ measures. Clinical Psychologist, 13, 1–9.
de passer de la recherche a la pratique.
` Claud, D. (2004, June). Efficiency variables in public behavioral health.
Presentation at the Heart and Soul of Change 2 International Conference,
Mots-cles: retroaction du client axee sur les resultats, recherche
´ ´ ´ ´ Austin, TX.
axee sur le patient, PCOMS, observations basees sur la pratique.
´ ´ Dew, S., & Riemer, M. (2003, March). Why inaccurate self-evaluation of
performance justifies feedback interventions. In L. Bickman (Ch.), Im-
proving outcomes through feedback intervention. Symposium conducted
References at the 16th Annual Research Conference, A System of Care for Chil-
dren’s Mental Health, Tampa, University of South Florida, The Louis de
Ackerman, S. J., Benjamin, L. S., Beutler, L. E., Gelso, C. J., Goldfried, la parte Florida Mental Health Institute.
M. R., Hill, C., . . . Rainer, J. (2001). Empirically supported therapy Duncan, B. (2010). On becoming a better therapist. Washington, DC:
relationships: Conclusions and recommendations of the Division 29 American Psychological Association.
Task Force. Psychotherapy: Theory, Research, Practice, Training, 38, Duncan, B. (2011). The Partners for Change Outcome Management Sys-
495– 497. doi:10.1037/0033-3204.38.4.495 tem (PCOMS): Administration, scoring, interpreting update for the
American Psychological Association Commission on Accreditation. Outcome and Session Ratings Scale. Jensen Beach, FL: Author.
(2011). Commission on Accreditation Implementing Regulations. Re- Duncan, B., & Miller, S. (2000). The heroic client. Doing client directed,
trieved from http://www.apa.org/Ed./accreditation/about/policies/ outcome informed therapy. San Francisco, CA: Jossey-Bass.
implementing-guidelines.pdf Duncan, B., & Miller, S. (2004). The Relationship Rating Scale. Jensen
American Psychological Association Presidential Task Force on Evidence- Beach, FL: Author.
Based Practice. (2006). Evidence-based practice in psychology. Ameri- Duncan, B., & Miller, S. (2007). The Group Session Rating Scale. Jensen
can Psychologist, 61, 271–285. doi:10.1037/0003-066X.61.4.271
Beach, FL: Author.
Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback
Duncan, B., Miller, S., & Sparks, J. (2003a). The Child Outcome Rating
to improve couple therapy outcomes: A randomized clinical trial in a
Scale. Jensen Beach, FL: Author.
naturalistic setting. Journal of Consulting and Clinical Psychology, 77,
Duncan, B., Miller, S., & Sparks, J. (2003b). The Child Session Rating
693–704. doi:10.1037/a0016062
Scale. Jensen Beach, FL: Author.
Anker, M., Owen, J., Duncan, B., & Sparks, J. (2010). The alliance in
Duncan, B., Miller, S., & Sparks, J. (2004). The heroic client: A revolu-
couple therapy. Journal of Consulting and Clinical Psychology, 78,
tionary way to improve effectiveness through client directed outcome
635– 645. doi:10.1037/a0020051
informed therapy (Rev. Ed.). San Francisco, CA: Jossey-Bass.
Baldwin, S., Berkeljon, A., Atkins, D., Olsen, J., & Nielsen, S. (2009).
Duncan, B., Miller, S., Sparks, J., Claud, D., Reynolds, L., Brown, J., &
Rates of change in naturalistic psychotherapy: Contrasting dose-effect
Johnson, L. (2003). The Session Rating Scale: Preliminary psychometric
and good-enough level models of change. Journal of Consulting and
Clinical Psychology, 77, 203–211. properties of a “working” alliance measure. Journal of Brief Therapy, 3,
Berg, I. K., & deShazer, S. (1993). Making numbers talk: Language in 3–12.
therapy. In S. Friedman (Ed.), The new language of change. New York, Duncan, B., Miller, S., Sparks, J., & Murphy, J. (2011). The Child Group
NY: Guilford Press. Session Rating Scale. Jensen Beach, FL: Author.
Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Duncan, B., Miller, S., Wampold, B., & Hubble, M. (Eds.). (2010). The
Noble, S., & Wong, E. (2004). Therapist variables. In M. J. Lambert heart and soul of change: Delivering what works in therapy (2nd ed.).
(Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior Washington DC: American Psychological Association.
change (5th ed., pp. 227–306). New York, NY: Wiley. Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the rules: A
Bohanske, R., & Franczak, M. (2010). Transforming public behavioral client-directed approach. New York, NY: Guilford Press.
health care: A case example of consumer directed services, recovery, Duncan, B., Sparks, J., Miller, S., Bohanske, R., & Claud, D. (2006).
and the common factors. In B. Duncan, S. Miller, B. Wampold, & M. Giving youth a voice: A preliminary study of the reliability and validity
Hubble (Eds.), The heart and soul of change: Delivering what works of a brief outcome measure for children. Journal of Brief Therapy, 5,
(2nd ed., pp. 299 –322). Washington DC: American Psychological As- 5–22.
sociation. Duncan, B., & Sparks, J. (2002). Heroic clients, heroic agencies: Partners
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of for change. Ft. Lauderdale, FL: Nova Southeastern University.
the working alliance. Psychotherapy, 16, 252–260. doi:10.1037/ Duncan, B., & Sparks, J. (2010). Heroic clients, heroic agencies: Partners
h0085885 for change (2nd ed.). Jensen Beach, FL: Author.
Bringhurst, D. L., Watson, C. W., Miller, S. D., & Duncan, B. L. (2006). Franklin, C., Corcoran, J., Nowicki, J., & Streeter, C. (1997). Using client
11. PARTNERS FOR CHANGE OUTCOME MANAGEMENT SYSTEM 103
self-anchored scales to measure outcomes in solution-focused therapy. Luborsky, L., Barber, J., Siqueland, L., Johnson, S., Najavits, L., Frank, A.,
Journal of Systemic Therapies, 16, 246 –265. & Daley, D. (1996). The revised Helping Alliance Questionnaire (HAQ-
Gillaspy, J. A., & Murphy, J. J. (2011). The use of ultra-brief client II). The Journal of Psychotherapy Practice and Research, 5, 260 –271.
feedback tools in SFBT. In C. W. Franklin, T. Trepper, E. McCollum, & Miller, S. D., & Duncan, B. L. (2000). The Outcome Rating Scale. Jensen
W. Gingerich (Eds.), Solution-focused brief therapy. New York, NY: Beach, FL: Author.
Oxford University Press, Miller, S. D., & Duncan, B. L. (2004). The Outcome and Session Rating
Hansen, N., Lambert, M., & Forman, E. (2002). The psychotherapy dose- Scales: Administration and scoring manual. Jensen Beach, FL: Author.
effect and its implications for treatment delivery services. Clinical Miller, S. D., Duncan, B. L., Brown, J., Sorrell, R., & Chalk, B. (2006).
Psychology: Science and Practice, 9, 329 –343. Using outcome to inform And improve treatment outcomes. Journal of
Harmon, S. C., Lambert, M. J., Smart, D. W., Hawkins, E. J., Nielsen, Brief Therapy, 5, 5–22.
S. L., Slade, K., & Lutz, W. (2007). Enhancing outcome for potential Miller, S. D., Duncan, B. L., Brown, J., Sparks, J., & Claud, D. (2003). The
treatment failures: Therapist/client feedback and clinical support tools. outcome rating scale: A preliminary study of the reliability, validity, and
Psychotherapy Research, 17, 379 –392. feasibility of a brief visual analog measure. Journal of Brief Therapy, 2,
Hatcher, R. L., & Barends, A. W. (1996). Patient’s view of psychotherapy: 91–100.
Exploratory factor analysis of three alliance measures. Journal of Con- Miller, S. D., Duncan, B. L., & Johnson, L. (2002). The Session Rating
sulting and Clinical Psychology, 64, 1326 –1336. Scale. Jensen Beach, FL: Author.
Hawkins, E. J., Lambert, M. J., Vermeersch, D. A., Slade, K., & Tuttle, K. Miller, S. L., Duncan, B. L., Sorrell, R., & Brown, G. S. (2005). The
(2004). The effects of providing patient progress information to thera- partners for change outcome management system. Journal of Clinical
pists and patients. Psychotherapy Research, 14, 308 –327. Psychology, 61, 199 –208.
Haynes, M. (2006, June). Agency implementation of client directed, out- National Consensus Conference on Mental Health Recovery and Mental
come informed services. Presentation at the Heart and Soul of Change 3 Health Systems Transformation. (2004). National Consensus Statement
International Conference, Bar Harbor, ME. on Mental Health Recovery. Rockville, MD. Retrieved from http://
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), mentalhealth.samhsa.gov/publications/allpubs/sma05– 4129/
Psychotherapy relationships that work (pp. 37– 69). New York, NY: Norcross, J. (2010). The therapeutic relationship. In B. Duncan, S. Miller,
Oxford University Press. B. Wampold, & M. Hubble (Eds.), The heart and soul of change:
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of
Delivering what works (2nd ed., pp. 113–142). Washington, DC: Amer-
the Working Alliance Inventory. Journal of Counseling Psychology, 64,
ican Psychological Association.
223–233.
Orlinsky, D. E., & Rønnestad, M. H. (2005). How psychotherapists de-
Howard, K. I., Kopte, S. M., Krause, M. S., & Orlinsky, D. E. (1986). The
velop: A study of therapeutic work and professional growth. Washing-
dose-effect relationship in psychotherapy. American Psychologist, 41,
ton, DC: American Psychological Association.
159 –164.
President’s New Freedom Commission on Mental Health. (2003). Achiev-
Howard, K. I., Moras, K., Brill, P. L., Martinovich, Z., & Lutz, W. (1996).
ing the Promise: Transforming mental health care in America. Final
Evaluation of psychotherapy: Efficacy, effectiveness, and patient prog-
report (DHHS Pub. No. SMA-03–3832). Rockville, MD. Retrieved from
ress. American Psychologist, 51, 1059 –1064.
http://www.mentalhealthcommission.gov/reports/FinalReport/toc.html
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical
Reese, R. J., Norsworthy, L. A., & Rowlands, S. R. (2009). Does a
approach to defining meaningful change in psychotherapy research.
continuous feedback system improve psychotherapy outcome? Psycho-
Journal of Consulting and Clinical Psychology, 59, 12–19.
therapy: Theory, Research, Practice, Training, 46, 418 – 431. doi:
Lambert, M. J. (2010). “Yes, it is time for clinicians to monitor treatment
10.1037/a0017901
outcome.” In B. L. Duncan, S. C., Miller, B. E. Wampold, & M. A.
Hubble (Eds.), Heart and soul of change: Delivering what works in Reese, R. J., Toland, M. D., Slone, N. C., & Norsworthy, L. A. (2010).
therapy (2nd ed., pp. 239 –266). Washington, DC: American Psycho- Effect of client feedback on couple psychotherapy outcomes. Psycho-
logical Association. therapy: Theory, Research, Practice, Training, 47, 616 – 630. doi:
Lambert, M. J., Hansen, N. B., Umphress, V., Lunnen, K., Okiishi, J., 10.1037/a0021182
Burlingame, G., . . . Reisinger, C. (1996). Administration and scoring Rosenberg, M. (1989). Society and the adolescent self-image (Rev. ed.).
manual for the OQ 45.2. Stevenson, MD: American Professional Cre- Middletown, CT: Wesleyan University Press.
dentialing Services. Sapyta, J., Riemer, M., & Bickman, L. (2005). Feedback to clinicians:
Lambert, M. J., & Ogles, B. (2004). The efficacy and effectiveness of Theory, research, and practice. Journal of Clinical Psychology: In Ses-
psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook sion, 61, 145–153.
of psychotherapy and behavior change (5th ed., pp. 139 –193). New Sharf, J., Primavera, L., & Diener, M. (2010). Droput and the therapeutic
York, NY: Wiley. alliance: Meta-analysis of adult individual psychotherapy. Psychother-
Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. apy: Theory, Research, Practice, Training, 47, 637– 645.
Psychotherapy, 48, 72–79. Shimokawa, K., Lambert, M. J., & Smart, D. W. (2010). Enhancing
Lambert, M. J., Whipple, J. L., Smart, D. W., Vermeersch, D. A., Nielsen, treatment outcome of patients at risk of treatment failure: Meta-analytic
S. L., & Hawkins, E. J. (2001). The effects of providing therapists with and mega-analytic review of a psychotherapy quality assurance system.
feedback on client progress during psychotherapy: Are outcomes en- Journal of Consulting and Clinical Psychology, 78, 298 –311.
hanced? Psychotherapy Research, 11, 49 – 68. Slade, K., Lambert, M. J., Harmon, S. C., Smart, D. W., & Bailey, R.
Lambert, M. J., Whipple, J. L., Vermeersch, D. A., Smart, D. W., Hawkins, (2008). Improving psychotherapy outcome: The use of immediate elec-
E. J., Nielsen, S. L., & Goates, M. K. (2002). Enhancing psychotherapy tronic feedback and revised clinical support tools. Clinical Psychology &
outcomes via providing feedback on client progress: A replication. Psychotherapy, 15, 287–303.
Clinical Psychology and Psychotherapy, 9, 91–103. Sparks, J. A., Muro, M. L. (2009). Client-directed wraparound: The client
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative as connector in community collaboration. Journal of Systemic Thera-
emotional states: Comparison of the Depression Anxiety Stress Scales pies, 28, 63–76.
(DASS) with the Beck Depression and Anxiety Inventories. Behaviour Sparks, J. A. (2012). Client-directed partnerships: Toward socially just
Research and Therapy, 33, 335–343. practices in mental health. Manuscript submitted for publication.
12. 104 DUNCAN
Tracey, T., & Kokotovic, A. (1989). Factor structure of the Working strategies in routine practice. Journal of Counseling Psychology, 58,
Alliance Inventory. Psychological Assessment: A Journal of Consulting 59 – 68.
and Clinical Psychology, 1, 207–210. Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy
Wampold, B. E., & Brown, G. (2005). Estimating therapist variability in dropout. Professional Psychology: Research and Practice, 24, 190 –195.
outcomes attributable to therapists: A naturalistic study of outcomes in
managed care. Journal of Consulting and Clinical Psychology, 73,
914 –923.
Whipple, J. L., Lambert, M. J., Vermeersch, D. A., Smart, D. W., Nielsen, Received December 5, 2011
S. L., & Hawkins, E. J. (2003). Improving the effects of psychotherapy: Revision received January 23, 2012
The use of early identification of treatment failure and problem solving Accepted February 6, 2012 Ⅲ