1 PREVENTION OF TREATMENT FAILURE: THE IMPORTANCE OF PROGRESS FEEDBACK & THE THERAPEUTIC ALLIANCE MIDST ALL THE CURRENT EMPHASIS ON TREATMENT GUIDELINES.

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PREVENTION OF TREATMENT FAILURE: THE

IMPORTANCE OF PROGRESS FEEDBACK &

THE THERAPEUTIC ALLIANCE MIDST ALL THE CURRENT EMPHASIS ON TREATMENT GUIDELINES

michael J. Lambert, Ph.D.michael J. Lambert, Ph.D.

[email protected][email protected]

Brigham Young UniversityBrigham Young University

The ProblemThe Problem

10-14% of SMI adults and 14 to 25% of 10-14% of SMI adults and 14 to 25% of child clients deteriorate in psychotherapychild clients deteriorate in psychotherapy

What shall we do about it????What shall we do about it????

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Identifying Cases for ReviewIdentifying Cases for Review

Little or NoNeed (50%)

ModerateNeed (43%)

GreatNeed (7%)

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Major IssuesMajor Issues1.1. Development of change sensitive brief Development of change sensitive brief

measures.measures.

2.2. Development of expected treatment Development of expected treatment response and method of predicting response and method of predicting treatment failure. treatment failure.

3.3. Automated method of providing Automated method of providing instantaneous feedback to clinicians and instantaneous feedback to clinicians and patients.patients.

4.4. Development of Problem-solving tools for Development of Problem-solving tools for failing cases failing cases

5.5. Clinical trails to test effects Clinical trails to test effects

Outcome Is:Outcome Is:

Symptom Distress—internal painSymptom Distress—internal pain e.g., I feel hopeless about the futuree.g., I feel hopeless about the future

Interpersonal ProblemsInterpersonal Problems e. g., I feel lonelye. g., I feel lonely

Social Role FunctioningSocial Role Functioning e.g., I feel angry enough at work to do e.g., I feel angry enough at work to do

something I may regretsomething I may regret Well beingWell being

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Substance Abuse ItemsSubstance Abuse Items

After heavy drinking I need a drink the After heavy drinking I need a drink the next morning to get going.next morning to get going.

I feel annoyed by people who criticize my I feel annoyed by people who criticize my drinking or drug use.drinking or drug use.

I have trouble at work/school because of I have trouble at work/school because of drinking/drug use.drinking/drug use.

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Substance Abuse Items Substance Abuse Items (continued)(continued)

How many days in the PAST WEEK did How many days in the PAST WEEK did you drink any alcohol(beer, wine, or you drink any alcohol(beer, wine, or liquor)? 0, 1, 2-3, 4-5, 6-7liquor)? 0, 1, 2-3, 4-5, 6-7

How many days in the PAST WEEK did How many days in the PAST WEEK did you use any drugs (Marijuana, cocaine, you use any drugs (Marijuana, cocaine, heroin, speed, others)? 0, 1, 2-3, 4-5, 6-7)heroin, speed, others)? 0, 1, 2-3, 4-5, 6-7)

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Measured WithMeasured With

45-item self-report (parent-report) scale 45-item self-report (parent-report) scale taken prior to each treatment session And taken prior to each treatment session And delivered to clinician in real time—within 2 delivered to clinician in real time—within 2 seconds.seconds.

The test provides a mental health “Vital The test provides a mental health “Vital Sign” or “Lab Test” that calibrates current Sign” or “Lab Test” that calibrates current functioning in relation to functioning prior functioning in relation to functioning prior to treatment AND expected treatment to treatment AND expected treatment response of similar clients WITH response of similar clients WITH ALERTSALERTS..

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ALERTSALERTS are Essential Because are Essential Because Clinicians are Overly OptimisticClinicians are Overly Optimistic

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Intervals For Group 25

60

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80

90

100

110

120

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Session

OQ

To

tal

Red

Yellow

Estimate

White

Blue

RED--upper 80% tolerance interval

YELLOW--upper 68% tolerance interval

Estimated Linefor group 25

WHITE--low er 68% tolerance interval

BLUE--low er 80% tolerance interval

GREEN--Betw een upper and low er 68% toleranceintervals

Final Outcome was predicted for 550 ClientsFinal Outcome was predicted for 550 Clients 3 were predicted to have a negative 3 were predicted to have a negative

outcomeoutcome 40 had a negative outcome40 had a negative outcome Staff identified only one caseStaff identified only one case Algorithms predicted 85% of those who had Algorithms predicted 85% of those who had

a negative outcome but false alarm signals a negative outcome but false alarm signals were given at a 2:1 ratio. were given at a 2:1 ratio.

How Well do Practitioners Predict How Well do Practitioners Predict Treatment Failure?Treatment Failure?

Hatfield (2010)Hatfield (2010)

Examined case notes of patients who Examined case notes of patients who deteriorated to see if therapists noted deteriorated to see if therapists noted worsening at the session it occurred.worsening at the session it occurred.

If the patient got 14 points worse was If the patient got 14 points worse was there any recognition? 21%there any recognition? 21%

If the patient got 30 points worse was If the patient got 30 points worse was there recognition? 32%there recognition? 32%

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PDA AdministrationPDA Administration

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Clinician ReportClinician Report

Assessment for Signal CasesAssessment for Signal Cases

My therapist seems glad to see meMy therapist seems glad to see me At times the tone of my therapist’s voice At times the tone of my therapist’s voice

seems criticalseems critical I could count on friendships when I could count on friendships when

something went wrongsomething went wrong I had thoughts of quitting therapyI had thoughts of quitting therapy

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Alliance Interventions• Pay careful attention to the amount of agreement between

you and your client concerning overall goals and the tasks necessary to achieve those goals

• Work with resistance be retreating when necessary and being supportive

• Provide a therapeutic rationale for your techniques, actions and behaviors

• Discuss the here and now therapeutic relationship– do not explain or defend yourself

• Spend more time exploring client feelings

SIX CLINICAL TRIALS IN WHICH WE ATTEMPTED TO REDUCE SIX CLINICAL TRIALS IN WHICH WE ATTEMPTED TO REDUCE DETERIORATION RATES BY PROVIDING PROGRESS FEEDBACK TO DETERIORATION RATES BY PROVIDING PROGRESS FEEDBACK TO PSYCHOTHERAPISTSPSYCHOTHERAPISTS

Lambert, et al. 2001Lambert, et al. 2001Lambert, et al. 2002Lambert, et al. 2002Whipple, et al. 2003Whipple, et al. 2003Hawkins, et al. 2005Hawkins, et al. 2005Harmon, et al. 2007Harmon, et al. 2007Slade, et al. 2008Slade, et al. 2008Crits Christoph et al 2011Crits Christoph et al 2011Simon, et al. Inpatient Eating Disorders, 2012Simon, et al. Inpatient Eating Disorders, 2012

Random assignment of patients to experimental condition blocked on therapist Random assignment of patients to experimental condition blocked on therapist (every therapist had patients for whom they received feedback and were denied (every therapist had patients for whom they received feedback and were denied feedback) N = 4,000feedback) N = 4,000

Research ProgramResearch Program

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60

65

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80

85

90

95

Pre-test Feedback Post-test

OQ

Tot

al S

core

OT_Fb III

OT-NFb III

NOT-NFb I & II

NOT-Fb I & II

NOT-Fb+CST III

Results (Outcome)Results (Outcome)

Recovered or Improved

No Change Deteriorated

NOT-NFb

(n = 286)

60 (21%) 165 (58%) 61 (21%)

NOT-Fb

(n = 298)

104 (35%) 154 (52%) 40 (13%)

NOT-Fb+CST

(n = 239)121 (51%)

102 (43%)16 (6%)

Substance Abuse OutcomesSubstance Abuse OutcomesCrits-Christoph, et al 2011 (Journal of Substance Abuse Crits-Christoph, et al 2011 (Journal of Substance Abuse

Treatment)Treatment)

Multi-site study—New York, Philadelphia, Multi-site study—New York, Philadelphia, Salt Lake CitySalt Lake City

304 patients assigned to feedback or no 304 patients assigned to feedback or no feedback within therapists feedback within therapists

Followed across 12 treatment sessions. Followed across 12 treatment sessions.

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2222

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BECOMING AN EMPIRICALLY-BECOMING AN EMPIRICALLY-VALIDATED VALIDATED

PSYCHOTHERAPIST: The value PSYCHOTHERAPIST: The value of applying patient- focused of applying patient- focused research in psychotherapy research in psychotherapy

practicepractice

Therapist Effects Can be DramaticTherapist Effects Can be Dramatic

The individual therapist plays a key role in The individual therapist plays a key role in outcome and this role is independent of outcome and this role is independent of school-based offerings.school-based offerings.

Variability of Client Outcome as a Variability of Client Outcome as a Function of the Therapist and What To Function of the Therapist and What To

Do About It. Do About It.

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Provider Profile Provider Profile Providers can profile real time change Providers can profile real time change

metrics for themselves—percent of cases metrics for themselves—percent of cases recovered, improved, no change & recovered, improved, no change & deteriorated—to determine strengths & deteriorated—to determine strengths & areas for improvementareas for improvement

Providers can view aggregate cases by Providers can view aggregate cases by diagnosis, gender, etc. for differential diagnosis, gender, etc. for differential effectiveness in case loadeffectiveness in case load

Providers contrast differential effectiveness Providers contrast differential effectiveness (e.g., diagnosis) with peers(e.g., diagnosis) with peers

Therapist Variability in OutcomeTherapist Variability in Outcome

Since 1996, 270 different professionals and trainees Since 1996, 270 different professionals and trainees have provided treatment. have provided treatment.

The CCC’s database includes nearly 27,009 individual, The CCC’s database includes nearly 27,009 individual, couple, family, biofeedback, and group sessions.couple, family, biofeedback, and group sessions.

179,000 OQ-45s have been gathered since 1996. 179,000 OQ-45s have been gathered since 1996. average improvement scores for the 26 current average improvement scores for the 26 current

professionals, compared with an average improvement professionals, compared with an average improvement score computed for all previous professional therapists score computed for all previous professional therapists and all past and present trainees. and all past and present trainees.

minimum of 186 clients per therapist to a maximum minimum of 186 clients per therapist to a maximum of 1,054 clients per therapist; of 1,054 clients per therapist;

On average, every therapist’s clients On average, every therapist’s clients improved. improved.

The average of improvement scores The average of improvement scores for all past professionals and all for all past professionals and all trainees is depicted in black.trainees is depicted in black.

Average improvement scores for 7 Average improvement scores for 7 therapists (in blue), are significantly therapists (in blue), are significantly better than this overall average.better than this overall average.

4 therapists (in red), had scores significantly 4 therapists (in red), had scores significantly worse than this overall average.worse than this overall average.

15 therapists (in green), had scores within 15 therapists (in green), had scores within

this average range.this average range.

Therapist 1's average improvement score is Therapist 1's average improvement score is particularly interesting, as it is significantly particularly interesting, as it is significantly better than 24 of the 25 other average better than 24 of the 25 other average improvement scores.improvement scores.

Nielsen & Okiishi, 2010Nielsen & Okiishi, 2010

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0 1 2 3 4 5 6 7 8 9

Session #

OQ

Tot

al S

core Whole Center

Therapist #1

Therapist#56

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In sum…In sum…

Ongoing monitoring & feedback:Ongoing monitoring & feedback: Increases overall outcomesIncreases overall outcomes Reduces treatment failuresReduces treatment failures Improves outcomes for substance abuse clientsImproves outcomes for substance abuse clients Increases service access by reallocation of staff Increases service access by reallocation of staff

timetime Identifies best practice groups/clinicians and Identifies best practice groups/clinicians and

those in need of peer-supervisionthose in need of peer-supervision Saves support staff time when using a fully Saves support staff time when using a fully

automated system.automated system.