HeartandSoulofChange

www.heartandsoulofchange.com 2011

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Barry Duncan,Barry Duncan, Psy.DPsy.D. www.heartandsoulofchange.com. www.heartandsoulofchange.com561.239.3640 www.whatsrightwithyou.com561.239.3640 www.whatsrightwithyou.com

[email protected]@comcast.net

The Heart & Soulof Change

Delivering What WorksIn Therapy


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••Since the 60’s, the # of modelsSince the 60’s, the # of modelshas grown from 60 to over 400…has grown from 60 to over 400…

••Each claims superiority inEach claims superiority inconceptualization and outcomeconceptualization and outcome

The result is fragmentation alongThe result is fragmentation alongtheoretical and disciplinary linestheoretical and disciplinary lines

Now over 100 so called evidenceNow over 100 so called evidencebased treatmentsbased treatments----effectivenesseffectivenessnot increased in 40 years…not increased in 40 years…


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The Dodo VerdictThe Dodo Verdict

••With few exceptions, partisan studiesWith few exceptions, partisan studiesdesigned to prove the unique effectsdesigned to prove the unique effectsof a given model have found noof a given model have found nodifferencesdifferences——nor has recent metanor has recent meta--analyses…analyses…The Dodo VerdictThe Dodo Verdict——thethemost replicated finding in themost replicated finding in thepsychological literaturepsychological literature

“Everybody has won and all“Everybody has won and allmust have prizes.”must have prizes.”

Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy.Journal of Orthopsychiatry, 6, 412-15.Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fidepsychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215.

••Considered most sophisticatedConsidered most sophisticatedcomparative clinical trial ever:comparative clinical trial ever:

••CBT, IPT, Drug, PlaceboCBT, IPT, Drug, Placebo

Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of GeneralPsychiatry, 46, 971-82.

••NoNo differencedifference in outcomein outcome••TheThe client’sclient’s rating of the alliance atrating of the alliance atthe second session the best predictorthe second session the best predictorof outcome across conditions.of outcome across conditions.

TDCRPThe Alliance

TDCRPThe Alliance


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••CBT, 12CBT, 12--step, & Motivationalstep, & MotivationalInterviewingInterviewing

••NONO difference in outcomedifference in outcome••The client’s rating of the allianceThe client’s rating of the alliancethe best predictor of:the best predictor of:

Treatment participation;Treatment participation;Drinking behavior duringDrinking behavior duringtreatment;treatment;Drinking at 12Drinking at 12--month FUmonth FUCOMBINE…same thingCOMBINE…same thing

Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29.Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK.Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journalof Consulting and Clinical Psychology, 65(4), 588-98.

Project MATCHThe Alliance

Project MATCHThe Alliance

Anton, S. et al., (2006). Combinedpharmaceutical and behavioralinterventions for alcoholdependence.. JAMA, 295, 203-217.

••600 Adolescents marijuana users:600 Adolescents marijuana users:••Significant coSignificant co--morbidity (3morbidity (3--12 problems).12 problems).

••Two arms (dose, type) and one ofTwo arms (dose, type) and one ofthree types of treatment in each arm:three types of treatment in each arm:

••Dose arm: MET+CBT (5 wks),Dose arm: MET+CBT (5 wks),MET+CBT (12 wks), Family SupportMET+CBT (12 wks), Family SupportNetwork (12 wks)+MET+CBT;Network (12 wks)+MET+CBT;••Type arm: MET/CBT (5 wks), ACRT (12Type arm: MET/CBT (5 wks), ACRT (12weeks), MDFT (12 wks).weeks), MDFT (12 wks).

The Dodo Also Rules Family TherapyThe Dodo Also Rules Family TherapyCannabis Youth Treatment ProjectCannabis Youth Treatment Project

No Difference! ApproachNo Difference! Approach accounted for 0% of the variance in outcome.accounted for 0% of the variance in outcome.AllianceAlliance predicted: Premature droppredicted: Premature drop--out; Substance abuseout; Substance abuse symptomssymptoms postpost--treatment, and cannabis use at 3 and 6 month followtreatment, and cannabis use at 3 and 6 month follow--up.up.


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What AboutEvidenced Based Treatment

What AboutEvidenced Based Treatment

Rosenzweig, S. (1936). Some implicit commonRosenzweig, S. (1936). Some implicit commonfactors in diverse methods in psychotherapy.factors in diverse methods in psychotherapy.Journal of Orthopsychiatry, 6Journal of Orthopsychiatry, 6, 412, 412--15.15.

••Dodo highlights fatal flaw: EfficacyDodo highlights fatal flaw: Efficacyover placebo or TAU is not efficacyover placebo or TAU is not efficacyover other approaches & not sayingover other approaches & not sayingmuchmuch——ifif a friend went out on adate, you asked about the guy, yourfriend replied, “He was better thannothing—he was unequivocallybetter than watching TV or washingmy hair.” How impressed?How impressed?

••And the conclusion…And the conclusion…

Implication of the Dodo Bird VerdictImplication of the Dodo Bird Verdict

All 400 approaches workAll 400 approaches workbecause:because:

Of factors common to allOf factors common to alltherapiestherapies

So what are the factors?So what are the factors?


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Client/Extratherapeutic Factors (87%)

Treatment Effects13%

Feedback Effects15-31%

Alliance Effects38-54%

Model/Technique8%

Model/Technique Delivered:Expectancy/AllegianceRationale/Ritual (GeneralEffects)

30-?%

Therapist Effects46-69%

Duncan, B. (2010). On becoming a better therapist.Washington DC: American PsychologicalAssociation

Becoming BetterBottom Line

Becoming BetterBottom Line

Suggestssomething different

Privilege clients’experience & rallytheir resources tothe cause

Suggestssomething different

Privilege clients’experience & rallytheir resources tothe cause

“The quality ofthe patient'sparticipation . . .[emerges] asthe mostimportantdeterminant ofoutcome."

Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years ofprocess -outcome research: In M. J. Lambert (Ed.), Bergin andGarfield’s handbook of psychotherapy and behavior change (5th ed.,pp. 307-390). New York: Wiley.


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DysfunctionDisorderDisabilityDiseaseDeficitDamagedNot Reliable or ValidNone ever related to

outcome

The Killer D’s ofThe Killer D’s of

Client DiminishmentClient Diminishment

“Psychotherapy is the only form of treatmentwhich, at least to some extent, appears to createthe illness it treats” Jerome Frank (Frank, 1961,p. 7).

Reliability: “To say that we've solved thereliability problem is just not true…It's beenimproved. But if you're in a situation with ageneral clinician it's certainly not very good.There's still a real problem, and it's not clearhow to solve the problem" Robert Spitzer, leadeditor of DSM III (Spiegel, 2005, p. 63).

Validity: “There is no definition of a mentaldisorder. It’s bullshit. I mean, you just can’tdefine it… these concepts are virtuallyimpossible to define precisely with bright lines atthe boundaries.” Allen Francis, lead editor ofDSM IV (Greenberg, 2010, p. 1).

More Quotable Quotes about Diagnosis

•Creates the Illness•Reliability not good•It’s BS


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Casting the Client in Heroic RolesCasting the Client in Heroic Roles

No formula here, more of an attituderequiring a balance betweenlistening empathically withmindfulness toward resources thatyou know are there.

Identify not what clients need, butwhat they already have in their worldthat can be put to use in reachingtheir goals

No formula here, more of an attituderequiring a balance betweenlistening empathically withmindfulness toward resources thatyou know are there.

Identify not what clients need, butwhat they already have in their worldthat can be put to use in reachingtheir goals

Finding the Heroic ClientFinding the Heroic Client

What are the qualities that describe you when

you are your very best? What were you doing

when these aspects became apparent to you?

What kind of person do these aspects describe?

Or, What kind of person do these aspects show an

aspiration toward?

What are the qualities that others would describe

In you when you are at your very best? What

were you doing when they noticed these aspects?


Or, what kind of person do these aspects show an

aspiration toward?

What are the qualities that describe you when

you are your very best? What were you doing

when these aspects became apparent to you?


Or, What kind of person do these aspects show an

aspiration toward?

What are the qualities that others would describe

In you when you are at your very best? What

were you doing when they noticed these aspects?


Or, what kind of person do these aspects show an

aspiration toward?


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Finding the Heroic ClientFinding the Heroic Client

Who was the first person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects?

Who was the last person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects?

Who in your life wouldn’t be surprised to seeyou stand up to these situations and prevail?What experiences would they draw upon tomake these conclusions about you? What“quintessentially you” stories would theytell?...Kim

When I am at my very best, I am_____________.

Who was the first person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects?

Who was the last person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects?

Who in your life wouldn’t be surprised to seeyou stand up to these situations and prevail?What experiences would they draw upon tomake these conclusions about you? What“quintessentially you” stories would theytell?...Kim

When I am at my very best, I am_____________.

Telling Heroic StoriesTelling Heroic Stories

What are the obvious and hiddenstrengths, resources, resiliencies,and competences contained in theclient’s story?

What are the competing stories—thestories of clarity, coping, endurance,and desire that exist simultaneouslywith the confusion, pain, suffering,and desperation?

What is already there to be recruitedfor change?

What are the obvious and hiddenstrengths, resources, resiliencies,and competences contained in theclient’s story?

What are the competing stories—thestories of clarity, coping, endurance,and desire that exist simultaneouslywith the confusion, pain, suffering,and desperation?

What is already there to be recruitedfor change? The Heroic Client


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Think of a Time in Your LifeThink of a Time in Your Life

Think of a time in your life that was very difficult.

What problems did this situation create for yourpersonal mental health as well as your family?

Did you use drugs or alcohol to get you through?

What pattern in your life does this story represent?

Who else knows this story about you?

What do you think they say this story says about whatdestructive patterns that you need to change?

Who wouldn’t be surprised that you are repeating thispattern now?

Think of a time in your life that was very difficult.

What problems did this situation create for yourpersonal mental health as well as your family?

Did you use drugs or alcohol to get you through?

What pattern in your life does this story represent?

Who else knows this story about you?

What do you think they say this story says about whatdestructive patterns that you need to change?

Who wouldn’t be surprised that you are repeating thispattern now?

Telling Heroic Stories…ImagineTelling Heroic Stories…Imagine

Think of a time in your life that was very difficult, butyou managed to get through it.

What personal resources did you draw on to getthrough this difficulty?

What family, spiritual, friend, or community supportdid you draw on to get through?

What does this story tell you about who you are andwhat you can do?

Who else knows this story about you? What do you think they say this story says about who

you are and what you are capable of? Who wouldn’t be surprised to see you stand up to this

problem and prevail?

Think of a time in your life that was very difficult, butyou managed to get through it.

What personal resources did you draw on to getthrough this difficulty?

What family, spiritual, friend, or community supportdid you draw on to get through?

What does this story tell you about who you are andwhat you can do?

Who else knows this story about you? What do you think they say this story says about who

you are and what you are capable of? Who wouldn’t be surprised to see you stand up to this

problem and prevail?


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The Heroic ClientThe Heroic Client

•• The Client:The Client:•• Change is a potent client factor,Change is a potent client factor,

weaving in and out clients’ livesweaving in and out clients’ livescreating many therapeuticcreating many therapeuticopportunities.opportunities.

•• Chance events:Chance events:•• Things that simply happenThings that simply happen

while the person happens to bewhile the person happens to bein therapy…in therapy…

Source: Howard, et al (1986). The dose effect response in psychotherapy. American Psychologist,41(2), 159-164.

Change in TreatmentChange in Treatment


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•Strong correlation between the maintenance of changeand the degree to which clients attribute it to their ownefforts.

•Participants who attribute changes to a med or therapist are lesslikely to maintain gains than those who viewed the improvementresulting from their own efforts.

•Those who attribute changes to their own efforts rather thanchance more likely to maintain gains regardless of the cause.

Maintaining ChangeMaintaining Change

Frank, J.D. (1976). Psychotherapy and the sense of mastery. In R.L. Spitzer et al. (eds). Evaluation ofPsychotherapies. Baltimore, MD: Johns Hopkins.Liberman, B. (1978). The maintenance and persistence of change. In J.D. Frank et al. (eds). Effective ingredients ofeffective psychotherapy. New York: Brunner Mazel.

Becoming Change FocusedBecoming Change Focused

Listen for a change!Listen for a change! AskAskabout and be curious aboutabout and be curious aboutchange: How did you dochange: How did you dothat? Where did that ideathat? Where did that ideacome from?come from?

Validate the clientsValidate the clientscontribution to change.contribution to change.How is (drug/tx program)How is (drug/tx program)helping access strengths andhelping access strengths andresources that have alwaysresources that have alwaysbeen there but were justbeen there but were justbeyond your grasp?beyond your grasp?

Listen for a change!Listen for a change! AskAskabout and be curious aboutabout and be curious aboutchange: How did you dochange: How did you dothat? Where did that ideathat? Where did that ideacome from?come from?

Validate the clientsValidate the clientscontribution to change.contribution to change.How is (drug/tx program)How is (drug/tx program)helping access strengths andhelping access strengths andresources that have alwaysresources that have alwaysbeen there but were justbeen there but were justbeyond your grasp?beyond your grasp?


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EncourageEncourage BeforeBeforeandand AfterAfter DistinctionsDistinctions

EncourageEncourage BeforeBeforeandand AfterAfter DistinctionsDistinctions

How did you decide that now was thetime for action?

What insights have you gained that youwere finally able to put into action?

What insights have you gained from thischange that will help you in the future?

What does this say about you, the kindof person that took the bull by the hornsat this time?

How did you do it? How will youmaintain the gains you have made?

How are you different now that youhave realized this change?

Ponder the difference in your self-imagebefore you changed and now….Chris

How did you decide that now was thetime for action?

What insights have you gained that youwere finally able to put into action?

What insights have you gained from thischange that will help you in the future?

What does this say about you, the kindof person that took the bull by the hornsat this time?

How did you do it? How will youmaintain the gains you have made?

How are you different now that youhave realized this change?

Ponder the difference in your self-imagebefore you changed and now….Chris

Client is the of ChangeClient is the of Change

Client’s Resources,Resiliencies, andRelational Support

Client’s View of theAlliance

Client’s View ofProgress&Expectation ofSuccess

Client’s Resources,Resiliencies, andRelational Support

Client’s View of theAlliance

Client’s View ofProgress&Expectation ofSuccess


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ClientsThe Heart of Change

ClientsThe Heart of Change

Client outcome feedbackmakes consumers thehistorians of their ownchange and recovery

Partnering w/clients tomonitor outcome engagesmost the potent factor ofchange

The Treatment of DepressionThe Treatment of DepressionCollaborative Research Project (TDCRP)Collaborative Research Project (TDCRP)

••Considered to be the most sophisticated comparativeConsidered to be the most sophisticated comparativeclinical trial ever conducted:clinical trial ever conducted:

••Four approaches (CBT, IPT, Drug, Placebo).Four approaches (CBT, IPT, Drug, Placebo).

Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of GeneralPsychiatry, 46, 971-82.

••NoNo difference in outcome between approachesdifference in outcome between approaches••TheThe client’sclient’s rating of the alliance at the second sessionrating of the alliance at the second sessionthe best predictor of outcome across conditions.the best predictor of outcome across conditions.••Tx model accounted for 0Tx model accounted for 0--2% of the variance…2% of the variance…


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TDCRP: top third psychiatristsgiving placebo bested bottomthird giving meds; clients ofbest therapists improve 50%more & dropped out 50%less; meds useful for clientsof more effective therapists,not for less.What accounts for thevariability?

Wampold, B., & Brown, J. (2006). Estimating variability inoutcomes attributable to therapists: A naturalistic study ofoutcomes in managed care. Journal of Consulting andClinical Psychology, 73 (5), 914-923.

Therapist DifferencesIncredible Variation Among Providers

Therapist DifferencesIncredible Variation Among Providers

Successful V. Unsuccessful ProvidersFocus on Strengths

Successful V. Unsuccessful ProvidersFocus on Strengths

Studied videos of 120sessions of 30 clients.

Unsuccessful providers focusedon problems, neglectedstrengths.

Successful providers focusedon strengths before moving toproblems….

Studied videos of 120sessions of 30 clients.

Unsuccessful providers focusedon problems, neglectedstrengths.

Successful providers focusedon strengths before moving toproblems….

Gassman, D. & Grawe, K. (2006). General change mechanisms: The relation between problem activation and resource activationin successful and unsuccessful therapeutic interactions. Clinical Psychology and Psychotherapy, 13, 1-11.


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Therapists Variables thatPredict Change

Therapists Variables thatPredict Change

Therapists with thebest results:

Are better at thealliance across clients;alliance ability accountsfor therapist differences

Alliance predicts changeover and above earlychange

Therapists with thebest results:

Are better at thealliance across clients;alliance ability accountsfor therapist differences

Alliance predicts changeover and above earlychange

Baldwin et al. (2007). Untangling the alliance-outcomecorrelation. Journal of Consulting and Clinical Psychology,75(6), 842-852.;Anker, Owen, Duncan, & Sparks (2010). The alliance incouple therapy. Journal of Consulting and ClinicalPsychology, 78(5), 635-645.Owen, Duncan, Anker, & Sparks (2011). Therapist variabilityin couple therapy. Manuscript submitted for publication.

Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass

Relationship FactorsRelationship Factors

The Alliance:The Alliance:

•• Relational BondRelational Bond•• Agreement onAgreement on goals• Agreement on tasksAgreement on tasks

Seven TimesSeven Times the Impact ofthe Impact ofModel/Technique…AccountsModel/Technique…Accountsfor Most of Therapistfor Most of TherapistVarianceVariance

3838--54%54%


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Means orMeans orMethods:Methods:Theory ofTheory ofChangeChange

Goals,Goals,MeaningMeaning

ororPurposePurpose

The Therapeutic AllianceThe Therapeutic Alliance

The AllianceThe Alliance

Client’s View of theClient’s View of theRelationshipRelationship

The Alliance:The Alliance:OverOver 10001000 Research FindingsResearch Findings

Quality of the alliance morepotent predictor of outcome thanorientation, experience, orprofessional discipline-- recallTDCRP, MATCH, CYT.

Clients rarely report negativereactions before deciding toterminate.

Same holds true for youth andfamily therapy


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Project MATCHProject MATCH

••No difference in outcome between voluntaryNo difference in outcome between voluntaryand mandated clients.and mandated clients.

••The only reliable predictor?The only reliable predictor?••The AllianceThe Alliance

Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29.Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participationand outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98.

What about theWhat about the mandatedmandated clients?clients?

••Increasingly, the relationship isIncreasingly, the relationship isviewed as merely “setting the stage”viewed as merely “setting the stage”for the “real” treatment:for the “real” treatment:

••Confronting distorted thoughts;Confronting distorted thoughts;••Recovering forgotten memories;Recovering forgotten memories;••Asking special questions;Asking special questions;••Tapping on or waving fingers in front of theTapping on or waving fingers in front of theface…but the data say:face…but the data say:

••The alliance deserves farThe alliance deserves farmoremore RESPECT…RESPECT…

Research into PracticeThe Alliance

Research into PracticeThe Alliance

Duncan, B. (2010). On becoming a better therapist. Washington, DC: APA.


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RelianceReliance on theon the AllianceAlliance

• Be friendly, responsive, andflexible (like a first date); stayclose to client’s experience.

• Empathy and Positive Regard:Validate. Legitimize the client’sconcerns/basic worth and theimportance of their struggle.

• Work on client’s goals period.

• Fit the client’s theory of change.

EmpathyCarl Rogers Was On To Something

EmpathyCarl Rogers Was On To Something

Empathy. A meta-analysis of47 studies: r of .26 betweentherapist empathy andpsychotherapy outcome,translating to ES of .32.

ES of model and techniquedifferences is but .20; Client’sperception of empathy morepowerful than any techniqueyou can ever wield.

Empathy. A meta-analysis of47 studies: r of .26 betweentherapist empathy andpsychotherapy outcome,translating to ES of .32.

ES of model and techniquedifferences is but .20; Client’sperception of empathy morepowerful than any techniqueyou can ever wield.


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Positive Regard: warm acceptanceof client w/o conditions.

When outcome & positive regardwere both rated by clients, 88%of studies found sig. relationship.Critical that clients think we viewthem positively.

Appreciation: appreciation ofpeople in general, their struggles,and of their humanity and innategoodness…Lisbeth

Positive Regard: warm acceptanceof client w/o conditions.

When outcome & positive regardwere both rated by clients, 88%of studies found sig. relationship.Critical that clients think we viewthem positively.

Appreciation: appreciation ofpeople in general, their struggles,and of their humanity and innategoodness…Lisbeth

Empathy Plus Positive RegardEquals Validation

Empathy Plus Positive RegardEquals Validation

You Know It Ain’t EasyWhy Do Think They Call It Work

You Know It Ain’t EasyWhy Do Think They Call It Work

Gotta try and understand theanger; gotta figure out a wayfor it all to make sense

Gotta find stuff about theclient to like, to appreciate

Gotta validate her experience,work on her goals, and gether involved in purposefulwork

Gotta try and understand theanger; gotta figure out a wayfor it all to make sense

Gotta find stuff about theclient to like, to appreciate

Gotta validate her experience,work on her goals, and gether involved in purposefulwork


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The Rubber Hose of Doubtand the Bright Light of BlameThe Rubber Hose of Doubt

and the Bright Light of Blame

Validation doesn’t mean you agree withwhat the client has done; means thatyou acknowledge the rest of the story!

Puts client’s actions in a context thatlegitimizes him/her as a human being.No wonder…

Clears a path for change because itdiffuses self doubt and dissipates selfloathing…Sam…Lisbeth

Validation doesn’t mean you agree withwhat the client has done; means thatyou acknowledge the rest of the story!

Puts client’s actions in a context thatlegitimizes him/her as a human being.No wonder…

Clears a path for change because itdiffuses self doubt and dissipates selfloathing…Sam…Lisbeth

You are the problem!You are to blame!

The Client’s Theory of ChangeThe Client’s Theory of Change

PrePre--existing beliefsexisting beliefsabout the problemabout the problemand changeand change

Source: Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the Rules. NewYork: Guilford.


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In the TDCRP, congruence betweenthe clients TOC and tx resulted in:Stronger therapeutic alliances;Longer duration in treatment; andImproved treatment outcomes.

The Client’s Theory of Change:The Client’s Theory of Change:Empirical FindingsEmpirical Findings

Elkin, I. (1999). “Patient-treatment fit" and early engagement in therapy. Psychotherapy Research. 9(4) 437-451.

PreferencesMeta-Analysis of 35 Studies

PreferencesMeta-Analysis of 35 Studies

Clients matched topreferred conditions wereless likely to drop out &improved more.

Type of preference (role,therapist, or tx) not sig.

Results underscorecentrality of incorporatingclient preferences

Clients matched topreferred conditions wereless likely to drop out &improved more.

Type of preference (role,therapist, or tx) not sig.

Results underscorecentrality of incorporatingclient preferences

Swift, J.K., Callahan, J.L. & Vollmer, B.M. Preferences. Journal of Clinical Psychology: In Session, 67, 155–165.


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Plurality Pays OffDifferential Efficacy with Current Client

Plurality Pays OffDifferential Efficacy with Current Client

Q: Does it resonate; does itfit client preferences; canboth get behind it?

Alliance skills: explore clientideas, discuss options,collaboratively plan, andnegotiate changes if benefitnot forthcoming.

Alliance in action. Litmustest: whether it engagesclient in purposive work.

Q: Does it resonate; does itfit client preferences; canboth get behind it?

Alliance skills: explore clientideas, discuss options,collaboratively plan, andnegotiate changes if benefitnot forthcoming.

Alliance in action. Litmustest: whether it engagesclient in purposive work.

Attitude ImportantAlliance is Central Filter

Attitude ImportantAlliance is Central Filter

Is what I am doing andsaying now building orrisking the alliance?

Doesn’t mean you can’tchallenge but ratherthat you have to earnthe right and, considerthe allianceconsequences

Is what I am doing andsaying now building orrisking the alliance?

Doesn’t mean you can’tchallenge but ratherthat you have to earnthe right and, considerthe allianceconsequences


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Alliance As An Overarching FrameworkThe Alliance is the Soul

Alliance As An Overarching FrameworkThe Alliance is the Soul

Transcends any beh & isa property of all—fromtech. to scheduling appt

Purpose is to engage inpurposive work

Have to earn it each &every time; alliance isour craft; practiceelevates to art

Transcends any beh & isa property of all—fromtech. to scheduling appt

Purpose is to engage inpurposive work

Have to earn it each &every time; alliance isour craft; practiceelevates to art

The AllianceThe of Change

The AllianceThe of Change

Alliance feedback enables a fitbetween client expectations,preferences, and services

Does not leave the alliance tochance—applying over 1000studies showing therelationship of the alliance topositive outcomes


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But What About This Client?But What About This Client?

While the data give generalguidance, it does little to informwhat will help a particular client.

To know what is therapeutic, theclient’s view regarding both thealliance and outcome is key.

The real question: Does this clientexperience this interaction at thistime and place to be therapeutic?And the only way to do this is viaclient feedback

While the data give generalguidance, it does little to informwhat will help a particular client.

To know what is therapeutic, theclient’s view regarding both thealliance and outcome is key.

The real question: Does this clientexperience this interaction at thistime and place to be therapeutic?And the only way to do this is viaclient feedback

Feedback As A Common FactorFeedback As A Common Factor

Overlaps with & affects allfactors—tie that binds

Soliciting feedback is aliving, process that engagesclients in monitoringoutcome, heightens hope,fits client preferences,maximizes therapist-clientfit, and is itself a corefeature of change.

Overlaps with & affects allfactors—tie that binds

Soliciting feedback is aliving, process that engagesclients in monitoringoutcome, heightens hope,fits client preferences,maximizes therapist-clientfit, and is itself a corefeature of change.


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40+ Years of Data Say…40+ Years of Data Say…

No one approach worksNo one approach worksbetter than another.better than another.No one approach worksNo one approach worksbetter than another.better than another.

Factors common across allFactors common across allapproaches account forapproaches account forchangechange——Feedback helps youFeedback helps youintegrate and enhanceintegrate and enhancethe effects of thesethe effects of thesefactorsfactors

Factors common across allFactors common across allapproaches account forapproaches account forchangechange——Feedback helps youFeedback helps youintegrate and enhanceintegrate and enhancethe effects of thesethe effects of thesefactorsfactors

PsychotherapyThe Good…

PsychotherapyThe Good…

Study after study,Study after study,and studies ofand studies ofstudies show thestudies show theaverage treatedaverage treatedclient is better offclient is better offthan 80% of thethan 80% of theuntreated sample.untreated sample.


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Recent study:Recent study:2,000+ providers2,000+ providers

6,000+ clients6,000+ clients

OutcomesOutcomesequivalent to RCTsequivalent to RCTsfor depression,for depression,specifically thespecifically theTDCRP.TDCRP.

Recent study:Recent study:2,000+ providers2,000+ providers

6,000+ clients6,000+ clients

OutcomesOutcomesequivalent to RCTsequivalent to RCTsfor depression,for depression,specifically thespecifically theTDCRP.TDCRP.

Minami, T., Wampold, B., Serlin, R. Hamilton, E., Brown, J., Kircher, J. (2008). BenchmarkingMinami, T., Wampold, B., Serlin, R. Hamilton, E., Brown, J., Kircher, J. (2008). Benchmarkingthe effectiveness of psychotherapy treatment for adult depression in a managed care environment.the effectiveness of psychotherapy treatment for adult depression in a managed care environment.Journal of Consulting and Clinical Psychology, 76(1), 116Journal of Consulting and Clinical Psychology, 76(1), 116--24.24.

Counseling WorksAs Good As RCTs

Counseling WorksAs Good As RCTs

PsychotherapyThe Bad…

PsychotherapyThe Bad…

Drop out ratesDrop out ratesaverageaverage 47%47%

TherapistsTherapistsvary… a lotvary… a lot


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And the UglyProviders Don’t Know

And the UglyProviders Don’t Know

20-70% range

Graded theireffectiveness, A+ to F—67% said A or better;none rated belowaverage.

ProvidersProviders don’t knowdon’t knowhow effective they arehow effective they are

20-70% range

Graded theireffectiveness, A+ to F—67% said A or better;none rated belowaverage.

ProvidersProviders don’t knowdon’t knowhow effective they arehow effective they are

Hansen, N., Lambert, M., Forman, E. (2002). Thepsychotherapy dose-response effect and itsimplications for treatment delivery services. ClinicalPsychology: Science and Practice, 9, 329-343.

Sapyta, J., Riemer, M., & Bickman, L. Feedback toclinicians: Theory, research, and practice. Journalof Clinical Psychology: In Session, 61, 145-153

The Result:Consumer Confidence Troubling

The Result:Consumer Confidence Troubling

APA asked: “Is this an importantreason why you might choosenot to seek help?”

The highest % responses werelack of ins. (87%) & cost (81%).

The 3rd was a lack of confidencein the outcome of tx (77%).

Despite tx efficacy, DOs are aproblem, many do not benefit,therapists vary in effectivenessand & there is a crisis ofconfidence among consumers.

APA asked: “Is this an importantreason why you might choosenot to seek help?”

The highest % responses werelack of ins. (87%) & cost (81%).

The 3rd was a lack of confidencein the outcome of tx (77%).

Despite tx efficacy, DOs are aproblem, many do not benefit,therapists vary in effectivenessand & there is a crisis ofconfidence among consumers.


29

To The Rescue: Partners forChange Outcome Management System

To The Rescue: Partners forChange Outcome Management System

Howard et al. (1996) advocatedfor the systematic eval. of clientresponse during treatment to“determine the appropriatenessof the current tx…the need forfurther tx…[and] prompt aclinical consultation for patientswho [were] not progressing atexpected rates”

Howard et al. (1996) advocatedfor the systematic eval. of clientresponse during treatment to“determine the appropriatenessof the current tx…the need forfurther tx…[and] prompt aclinical consultation for patientswho [were] not progressing atexpected rates”

Feedback and OutcomeLambert’s Six Trials

Feedback and OutcomeLambert’s Six Trials

All 6 sig. gains for feedback

22% of TAU at-risk casesimproved compared with 33%for feedback to therapists,39% for feedback totherapists & clients, & 45%when supplemented withsupport tools

A strong case for routinemeasurement of outcome ineveryday clinical practice

All 6 sig. gains for feedback

22% of TAU at-risk casesimproved compared with 33%for feedback to therapists,39% for feedback totherapists & clients, & 45%when supplemented withsupport tools

A strong case for routinemeasurement of outcome ineveryday clinical practice


30

Feedback v TAU;Both persons reliableor sig. change—50.5% v. 22.6%;ES: .50; 4 xs # ofclin. sig. change

FU: TAU-34.2% v.18.4% Feedbacksep./divorce rate

Feedback v TAU;Both persons reliableor sig. change—50.5% v. 22.6%;ES: .50; 4 xs # ofclin. sig. change

FU: TAU-34.2% v.18.4% Feedbacksep./divorce rate

Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback toimprove couple therapy outcomes: A randomized clinical trial in anaturalistic setting. Journal of Consulting and Clinical Psychology,77(4), 693-704.

Becoming BetterIsn’t It Good, Norwegian Wood

Becoming BetterIsn’t It Good, Norwegian Wood

Reese, Norsworthy, & Rowlands (2009)First Independent Study

Reese, Norsworthy, & Rowlands (2009)First Independent Study

N=148: Feedback groupdoubled controls (10.4vs. 5.1 pts); ES: .48

Like Norway study,clients, regardless of riskstatus, benefit fromcontinuous feedback

And also a replicationstudy published

N=148: Feedback groupdoubled controls (10.4vs. 5.1 pts); ES: .48

Like Norway study,clients, regardless of riskstatus, benefit fromcontinuous feedback

And also a replicationstudy published

Reese, R., Norsworthy, L., &Rowlands, S. (2009). Does acontinuous feedback modelimprove psychotherapyoutcomes? Psychotherapy,46,418-431.

Reese, R., Toland, M., Slone, N.,& Norsworthy, L. (2010). Effectof client feedback on couplepsychotherapy outcomes.Psychotherapy, 47, 616-630.


31

Meta-analysis by Lambert & Shimokawa (2011)of PCOMS (the ORS and SRS)

Those in feedback group had3.5 higher odds of experiencingreliable change

Those in feedback group had lessthan half the odds of experiencingdeterioration

Feedback attained .48 ES

Lambert, M., & Shimokawa, K. (2011). Collecting client feedback. In J. Norcross (Ed.),Psychotherapy relationships that work, 2nd ed. New York: Oxford University Press

Effects on EfficiencyCancellations, No Shows, LOS

Effects on EfficiencyCancellations, No Shows, LOS

Claude (reported in Bohanske &Franczak) compared ave. # ofsessions, canc., no shows, and % oflong-term cases before and after OMin 2130 closed cases in a CMHC.

Ave. # of sessions dropped 40% (10to 6) while outcomes improved by7%; canc. and no show rates werereduced by 40% and 25%; and % oflong term null cases diminished by80% (10% to 2%).

An estimated savings of $489,600.

Claude (reported in Bohanske &Franczak) compared ave. # ofsessions, canc., no shows, and % oflong-term cases before and after OMin 2130 closed cases in a CMHC.

Ave. # of sessions dropped 40% (10to 6) while outcomes improved by7%; canc. and no show rates werereduced by 40% and 25%; and % oflong term null cases diminished by80% (10% to 2%).

An estimated savings of $489,600.

Bohanske, R., & Franczak, M. (2010).Transforming public behavioral healthcare: Acase example of consumer directed services,recovery, and the common factors. In B.Duncan et al. (Eds.) The Heart and Soul ofChange: Delivering What Works, 2nd Ed.Washington, DC: AmericanPsychological Association.


32

Becoming BetterRecapture Your At Risk Clients

Becoming BetterRecapture Your At Risk Clients

Feedback tailors therapybased on response,provides an early warningsystem to prevents drop-outs & negative outcomes,& solves therapistvariability—feedbackimproves performance

Feedback tailors therapybased on response,provides an early warningsystem to prevents drop-outs & negative outcomes,& solves therapistvariability—feedbackimproves performance

And…FinallyOperationalizes Recovery

And…FinallyOperationalizes Recovery

Puts the client’s voicecenter stage

Allows services to beclient and family driven

Brings consumers intothe inner circle ofdecisions

Partners in monitoringthe benefit and fit ofservices

Puts the client’s voicecenter stage

Allows services to beclient and family driven

Brings consumers intothe inner circle ofdecisions

Partners in monitoringthe benefit and fit ofservices


33

First Things FirstWhy You Might Be Reluctant


Finding out is risky

What if you find out thatyou are not so good? Whatif you are in the wrongprofession?

The only way we improveis thru feedback. It takescourage. But so doeswalking in a room withsomeone in distress.

Finding out is risky

What if you find out thatyou are not so good? Whatif you are in the wrongprofession?

The only way we improveis thru feedback. It takescourage. But so doeswalking in a room withsomeone in distress.

Norway: 9 of 10 gotbetter outcomes

Feedback raisedeffectiveness of the lowerones to their moresuccessful colleagues.

Therapist in loweffectiveness groupbecame the BEST withfeedback!

Norway: 9 of 10 gotbetter outcomes

Feedback raisedeffectiveness of the lowerones to their moresuccessful colleagues.

Therapist in loweffectiveness groupbecame the BEST withfeedback!

Regarding Therapist VariabilityFeedback Improves OutcomesRegarding Therapist VariabilityFeedback Improves Outcomes


34

Counselor's Outcomes(n=30 or more case s)

00.20 .4

0 .60 .8

11 .2

1 .41 .61 .8

1(n

=94)

2(n

=74)

3(n

=67)

4(n

=65)

5(n

=59)

6(n

=58)

7(n

=55)

8(n

=50)

9(n

=48)

10(n

=48)

11(n

=47)

12(n

=47)

13(n

=41)

14(n

=41)

15(n

=40)

16(n

=39)

17(n

=37)

18(n

=35)

19(n

=34)

20(n

=31)

21(n

=31)

22(n

=30)

Counselor

Eff

ect

siz

e

M ean E ffec t S ize for all Cases

Miller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005). The Partners for ChangeMiller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005). The Partners for ChangeOutcome Management System.Outcome Management System. Journal of Clinical Psychology, 61Journal of Clinical Psychology, 61(2), 199(2), 199--208.208.

Provider VariationFeedback Improves Effectiveness

Provider VariationFeedback Improves Effectiveness

Many BelieveThey Already Know

Many BelieveThey Already Know

The info the measuresreveal—that are attuned toclient’s experience & theforms superfluous.

Norway study: all therapistsbelieved they already acquiredoutcome & alliance info—thatformal feedback wouldn’timprove their effectiveness.

9 of 10 improved; only 1correct.

The info the measuresreveal—that are attuned toclient’s experience & theforms superfluous.

Norway study: all therapistsbelieved they already acquiredoutcome & alliance info—thatformal feedback wouldn’timprove their effectiveness.

9 of 10 improved; only 1correct.


35

You might be thinkingthat you need morepaperwork like a hole inthe head. Therapists canget really worked upover anything that addspaperwork, especiallywhen they don’t see itas clinically useful.

You might be thinkingthat you need morepaperwork like a hole inthe head. Therapists canget really worked upover anything that addspaperwork, especiallywhen they don’t see itas clinically useful.



Feedback about the benefit& fit need not becumbersome or intrusive.Only a couple of minutes &no intrusive questions.

Feedback the best hope toimprove, clients appreciateyour dedication to getting itright, & it is painless andcan fit your natural way.

Feedback about the benefit& fit need not becumbersome or intrusive.Only a couple of minutes &no intrusive questions.

Feedback the best hope toimprove, clients appreciateyour dedication to getting itright, & it is painless andcan fit your natural way.




36

PCOMS: Getting StartedJust the Facts Ma’am

PCOMS: Getting StartedJust the Facts Ma’am

The nuts & bolts, forstarting PCOMS withyour next client

Feedback is the wayto transcendaverage.

The nuts & bolts, forstarting PCOMS withyour next client

Feedback is the wayto transcendaverage.

Skill Building: Partners for ChangeOutcome Management System

Skill Building: Partners for ChangeOutcome Management System

3 Skills of PCOMS (TheThree I’s)

Introducing theMeasures

Integrating ClientFeedback into Practice

Informing and TailoringServices Based on ClientFeedback

3 Skills of PCOMS (TheThree I’s)

Introducing theMeasures

Integrating ClientFeedback into Practice

Informing and TailoringServices Based on ClientFeedback


37

Nuances of the MeasuresNot a Perfunctory Piece of Paper

Nuances of the MeasuresNot a Perfunctory Piece of Paper

Administering But Don’t Get It. Clients MustUnderstand Purpose (monitoring outcome,privileging their perspective); Therapists MustUnderstand Same + Make Them Meaningful

Administering, Using Some, But Not theClinical Cutoff or Numbers…Heuristic ClinicalUse but No Continuity or Coherence

Administering, Using Some, But NotConnecting to Client’s Experience or Reasonsfor Service; Data Integrity Questionable

Administering the SRS, But Seeing asReflective of Competence Rather than anAlliance Building Tool

Administering But Don’t Get It. Clients MustUnderstand Purpose (monitoring outcome,privileging their perspective); Therapists MustUnderstand Same + Make Them Meaningful

Administering, Using Some, But Not theClinical Cutoff or Numbers…Heuristic ClinicalUse but No Continuity or Coherence

Administering, Using Some, But NotConnecting to Client’s Experience or Reasonsfor Service; Data Integrity Questionable

Administering the SRS, But Seeing asReflective of Competence Rather than anAlliance Building Tool

The First SessionAll Aboard

The First SessionAll Aboard

Have to be on boardwith two things: haveto think privileging theclient is a good idea;and have to want tobe accountable.

Have to be on boardwith two things: haveto think privileging theclient is a good idea;and have to want tobe accountable.


38

Client Privilege and Social JusticeClients Have Been Missing PersonsClient Privilege and Social Justice

Clients Have Been Missing Persons

Despite well-intentionedefforts, the infrastructure oftherapy (paperwork,policies, procedures, andprofessional language) canreify non-contextualizeddescriptions of clientproblems and silence clientviews, goals, andpreferences.

The Measures and Social Justice“Leveling” the Counseling ProcessThe Measures and Social Justice

“Leveling” the Counseling Process

Invites clients into inner

circle of decision making

Available in multiple

languages

Voice to diversity and the

disenfranchised

Local culture and context

over privileged knowledge

Invites clients into inner

circle of decision making

Available in multiple

languages

Voice to diversity and the

disenfranchised

Local culture and context

over privileged knowledge


39

••Client’sClient’s rating of therating of thealliancealliance the best predictor ofthe best predictor ofengagement and outcome.engagement and outcome.

••Client’sClient’s subjectivesubjectiveexperience of change earlyexperience of change earlyin the process the bestin the process the bestpredictor of success for anypredictor of success for anyparticular pairing.particular pairing.

Starting WithStarting With the Predictorsthe PredictorsChange and the AllianceChange and the Alliance

Howard, K. et al. (1986). The dose-effect response in psychotherapy.American Psychologist, 41, 159-164.

A

B

•The bulk ofchangeoccurs soonerrather thanlatter

Who drops out?

Sooner Rather Than Later


40

Baldwin, S., Berkeljon, A., Atkins, D., Olsen, J., & Nielsen, S. (2009). Rates of change in naturalisticpsychotherapy: Contrasting dose-effect and good-enough level models of change. Journal ofConsulting and Clinical Psychology, 77(2), 203-211.

Some clients do takelonger, but the mythologynever dies

N=4676; 77% attended 8or less, and 91% 12 or less

Note that even for theclients who take longer,change starts early…just isflatter

Cannabis Youth Treatment Project

Project MATCH

http://www.chestnut.org/LI/Posters/CYT_%20MF_APA.pdfBabor, T.F., & DelBoca, F.K. (eds.) (2003). TreatmentMatching in Alcoholism. United Kingdom: Cambridge, 113.

Early change intreatment is arobust predictorof outcome andretention intreatment.Gotta measureoutcome!

It’s A FactEarly Change is The Rule


41

Early Change is the RuleTDCRP

Early Change is the RuleTDCRP

Conclusions: Early change is an important factor for theprediction of short- and long-term outcome in therapy.

Lutz, W., Stulz, N., & Köck, K. (2009). Patterns of early change and their relationship to outcome and follow-upamong patients with major depressive disorders. Journal of Affective Disorders 118(1), 60-68.

••Scored to theScored to thenearest millimeter.nearest millimeter.

••Add the fourAdd the fourscales togetherscales togetherfor the total score.for the total score.

••Give at theGive at thebeginning of thebeginning of thevisit; Clientvisit; Clientplaces a markplaces a markon the line.on the line.

••Each line 10Each line 10cm (100 mm) incm (100 mm) inlength.length.

•Reliable, valid,feasible

Becoming BetterMeasuring Outcome

Becoming BetterMeasuring Outcome


42

CORSCORS

•When scheduling, providerationale for seeking feedback;convey commitment to their goalsand highest quality of service…inyour own words•Work a little differently;•If we are going to be helpfulshould see signs sooner ratherthan later; If not helpful, we’ll seekconsultation & consider a referral.•No one has ever said: Bad idea!

Becoming BetterCreating A Culture of Feedback

Becoming BetterCreating A Culture of Feedback


43

The Outcome Rating ScaleAn Introduction

The Outcome Rating ScaleAn Introduction

The ORS is an outcome measure that allowsus to track where you’re at, how you’re doing,how things are changing or if they are not. Itallows us to determine whether the therapy isbeing helpful so we can do something differentif it’s not. It also is way to make sure that yourperspective stays central here, that we areaddressing what you think is most important.It only takes a minute to fill out and mostclients find it to be very helpful. Would yougive it a try?

The ORS is an outcome measure that allowsus to track where you’re at, how you’re doing,how things are changing or if they are not. Itallows us to determine whether the therapy isbeing helpful so we can do something differentif it’s not. It also is way to make sure that yourperspective stays central here, that we areaddressing what you think is most important.It only takes a minute to fill out and mostclients find it to be very helpful. Would yougive it a try?

The First SessionWhatever It TakesThe First Session

Whatever It Takes

You can’t over-explain…

Clients get this. Face validity.

Whatever explanation theclient gives is ok. Some willsay: “You mean like poor towell?” or “Like 1 to 10?”

It’s their subjectiveexperience that matters sotheir understanding of themeasure is paramount.

You can’t over-explain…

Clients get this. Face validity.

Whatever explanation theclient gives is ok. Some willsay: “You mean like poor towell?” or “Like 1 to 10?”

It’s their subjectiveexperience that matters sotheir understanding of themeasure is paramount.


44

Looking Like a KlutzWe’re All Bozos on this Bus

Looking Like a KlutzWe’re All Bozos on this Bus

Score the marks. Need a cmruler. Many will not try—fear oflooking like a bozo.

Worry about measuring marks& adding the scores. 4 marks &4 scores, not regressionequations. Practice until youfeel confident.

But, it’s okay to look inept fromtime to time with clients. Andbelieve me, however you do itwon’t be as bad as I’ve done it.

Score the marks. Need a cmruler. Many will not try—fear oflooking like a bozo.

Worry about measuring marks& adding the scores. 4 marks &4 scores, not regressionequations. Practice until youfeel confident.

But, it’s okay to look inept fromtime to time with clients. Andbelieve me, however you do itwon’t be as bad as I’ve done it.

Becoming BetterGraphing: A Helpful Visual

Becoming BetterGraphing: A Helpful Visual

Adds a visual component—another way to focus tx

At a glance tells the story ofthe client’s progress.

Allows you to dispense ofthe previous measures.

Indispensable with couples& families, helps discussmultiple viewpoints

Adds a visual component—another way to focus tx

At a glance tells the story ofthe client’s progress.

Allows you to dispense ofthe previous measures.

Indispensable with couples& families, helps discussmultiple viewpoints


45

•Can easily see indv. &family progress fromsession to session

•Can comment on other’sscores in relation to own

•Invites family discussionabout the next steps

•A visual indication of theneed for changingapproach, continuing, orending.

Using Graphs With Families

The Three Ring Circus:Making Measures Work with Families

The Three Ring Circus:Making Measures Work with Families

•Invite all members of the familyto participate.

•When child is presented as theproblem, use CORS with thechild & parents

•Invite all members of the familyto interpret.

•Summarize progress as entrypoint into the meeting.

•Summarize alliance as exit outof the meeting.


46

The First MeetingThe “Clinical Cutoff”

The First MeetingThe “Clinical Cutoff”

05

1015

2025

30

3540

1st 2nd 3rd 4th

Session Number

Ou

tco

me

Sco

re

Actual Score Line 2 25th % 75th %

••The dividing line between aThe dividing line between aclinical & “nonclinical & “non--clinical”clinical”population (25). For childrenpopulation (25). For children(32) & adolescents (28);(32) & adolescents (28);caretakers (28)caretakers (28)

••Between 25Between 25--33% score in33% score inthe “nonthe “non--clinical” range.clinical” range.

••The slope of changeThe slope of changedecreases as clients approachdecreases as clients approachthe cutoff.the cutoff.

The Clinical CutoffOnly 2 Choices

The Clinical CutoffOnly 2 Choices

Either above or below.

Mention client score as itrelates to the cutoff & havethe client make sense of it.

Scores under cutoff mayseem more straightforward

Reporting distress similar toothers seeking services—the lower the score, thehigher the distress. Lookingfor a change.

Either above or below.

Mention client score as itrelates to the cutoff & havethe client make sense of it.

Scores under cutoff mayseem more straightforward

Reporting distress similar toothers seeking services—the lower the score, thehigher the distress. Lookingfor a change.


47

0

10

20

30

40

1 2 3 4 5 6 7 8 9 10

Session number

OR

Ss

co

re

Projected change 75th percentile ORS Scores

Estimated Clinical Cutoff 25th percentile

Initial Information…Initial Information…

••Client’s scoreClient’s scoreis withinis within thetheclinical range.clinical range.

••Scoring moreScoring morelike people inlike people intherapy andtherapy andwantingwantingsomething tosomething tochange…wavychange…wavy

7.6

5.7

7.5

8.0

ORS: An ExampleORS: An Example

Total =Total = 28.828.8

••What can we gleanWhat can we gleanclinicallyclinically from thisfrom thisclient’s scores inclient’s scores inaddition to being aboveaddition to being abovethe clinical cut off?the clinical cut off?

••How could we use thisHow could we use thisinformation to begin orinformation to begin orfocus the session?focus the session?


48

••Explore why the client enteredExplore why the client enteredtherapy…two reasons: circumscribedtherapy…two reasons: circumscribedproblem or mandated/coercedproblem or mandated/coerced••If mandated, ask for the referral’sIf mandated, ask for the referral’srating as a catalyst for conversation…rating as a catalyst for conversation…doesn’t mean they are lyingdoesn’t mean they are lying••Focus on circumscribed problems orFocus on circumscribed problems orissues at handissues at hand••Avoid exploratory or “depthAvoid exploratory or “depth--oriented” techniques or stirring theoriented” techniques or stirring thecauldroncauldron

The First MeetingOver the Clinical Cutoff

The First MeetingOver the Clinical Cutoff

Over the CutoffThe Wicked WitchOver the Cutoff

The Wicked Witch

People over cutoff are ahigher risk of deterioration.

Why?

We don our Wicked Witchcostume, growing warts & ahumongous nose, and westir the cauldron. Laughingdevilishly we shriek, “Ohyou think things are goingokay do you, we’ll seeabout that, my pretty!”

People over cutoff are ahigher risk of deterioration.

Why?

We don our Wicked Witchcostume, growing warts & ahumongous nose, and westir the cauldron. Laughingdevilishly we shriek, “Ohyou think things are goingokay do you, we’ll seeabout that, my pretty!”


49

Take Clients at Face ValueTake Clients at Face Value

Don’t interpret highscores as amisrepresentation

It is the way the clientsees him or herself

Don’t have to see aproblem to be helped

Other’s ratings importanttoo

Don’t interpret highscores as amisrepresentation

It is the way the clientsees him or herself

Don’t have to see aproblem to be helped

Other’s ratings importanttoo

First Session: Connect ORS to theClient’s Described Experience

First Session: Connect ORS to theClient’s Described Experience

At some point,connect the client’sdescribed experienceof their lives to themarks on the scales

At some point,connect the client’sdescribed experienceof their lives to themarks on the scales


50

The ORSThe Bare Bones

The ORSThe Bare Bones

No specific content otherthan domains—a skeleton towhich clients add the flesh &blood of their experiences.

At the moment clientsconnect the marks with whatthey find distressing, the ORSbecomes a meaningfulmeasure of their progressand potent clinical tool.

No specific content otherthan domains—a skeleton towhich clients add the flesh &blood of their experiences.

At the moment clientsconnect the marks with whatthey find distressing, the ORSbecomes a meaningfulmeasure of their progressand potent clinical tool.

Get A Good RatingMake Sure

Get A Good RatingMake Sure

Transparency is therule, not confrontationor judgment

Darrell and AngelinaJolie

Brandy

Ray

Transparency is therule, not confrontationor judgment

Darrell and AngelinaJolie

Brandy

Ray


51

Has to beRelevant to theWork

Or Becomes anEmotionalThermometer ofDay to Day Life

Has to beRelevant to theWork

Or Becomes anEmotionalThermometer ofDay to Day Life

Integrating the MeasuresProblems and Challenges?

••Client’sClient’s rating of therating of thealliancealliance the best predictor ofthe best predictor ofengagement and outcomeengagement and outcome..

40 Years of Data say…40 Years of Data say…

••Client’sClient’s subjective experiencesubjective experienceof change early in the processof change early in the processthe best predictor of successthe best predictor of successfor any particular pairing.for any particular pairing.


52

Clients drop out for 2reasons: therapy is not helping(monitor outcome) & allianceproblems—not engaged orturned on. Direct way toimprove effectiveness is tokeep people engaged intherapy.

Gotta measure the alliance

Quickest WayPrevent Drop Out

Quickest WayPrevent Drop Out

The Session Rating ScaleMeasuring the AllianceThe Session Rating ScaleMeasuring the Alliance

••Give at the endGive at the endof session;of session;

••Each line 10 cmEach line 10 cmin length;in length;

••Score in cm toScore in cm tothe nearest mm;the nearest mm;

••Discuss withDiscuss withclient anytimeclient anytimetotal score fallstotal score fallsbelowbelow 3636


53

Becoming BetterA Culture of Feedback with the SRS

Becoming BetterA Culture of Feedback with the SRS

•When scheduling a firstappointment, provide a rationalefor seeking feedback regarding thealliance.

•Work a little differently;•Want to make sure that you aregetting what you need;

•Take the “temperature” at the end ofeach visit;•Feedback is critical to success.

•Restate the rationale prior toadministering the scale.

•How not to do the SRS


54

The Session Rating ScaleAn Introduction

The Session Rating ScaleAn Introduction

Let’s take a minute and have you fill out theother form that asks your opinion about ourwork together. It’s kind of like taking thetemperature of our relationship today. Arewe too hot or too cold? Do I need to adjustthe thermostat? This information helps mestay on track. The ultimate purpose of usingthese forms is to make every possible effortto make our work together beneficial. Ifsomething is amiss, you would be doing methe best favor if you let me know. Can youhelp me out?

Let’s take a minute and have you fill out theother form that asks your opinion about ourwork together. It’s kind of like taking thetemperature of our relationship today. Arewe too hot or too cold? Do I need to adjustthe thermostat? This information helps mestay on track. The ultimate purpose of usingthese forms is to make every possible effortto make our work together beneficial. Ifsomething is amiss, you would be doing methe best favor if you let me know. Can youhelp me out?

The Session Rating ScaleTraditionally

The Session Rating ScaleTraditionally Told us with their feetWill let us know on SRS

before telling/bolting. Takes work for candor.Disparity in power &

socio- economic, ethnic,or racial diff., can makeit tough. When was thelast time you told yourphysician, “You'remaking a big mistake"?

Told us with their feetWill let us know on SRS

before telling/bolting. Takes work for candor.Disparity in power &

socio- economic, ethnic,or racial diff., can makeit tough. When was thelast time you told yourphysician, “You'remaking a big mistake"?


55

But Don’t StressIt’s Okay

But Don’t StressIt’s Okay

Keep encouraging client tolet you know…

Have to KNOW: No badnews. Not a measure ofcompetence or anythingnegative about you or theclient. Gift from the clientthat helps you to be better.

Unless you really want it,you are unlikely to get it.

You won’t get it fromeveryone.

Keep encouraging client tolet you know…

Have to KNOW: No badnews. Not a measure ofcompetence or anythingnegative about you or theclient. Gift from the clientthat helps you to be better.

Unless you really want it,you are unlikely to get it.

You won’t get it fromeveryone.

The Session Rating ScaleA Quick Visual Check

The Session Rating ScaleA Quick Visual Check

Scores < 36 or 9cms shouldbe discussed.

SRS is good or its not. Eitherthank the client for thefeedback, & invite them toshare future concerns; orthank client & explore whytheir ratings are lower sothat you can fix the concern.

Building the Alliance

Scores < 36 or 9cms shouldbe discussed.

SRS is good or its not. Eitherthank the client for thefeedback, & invite them toshare future concerns; orthank client & explore whytheir ratings are lower sothat you can fix the concern.

Building the Alliance


56

Thankingand InvitingThanking

and Inviting Let me just take a second

here to look at this SRS—it’skind of like a thermometerthat takes the temperature ofour meeting here today. Wow,great, looks like we are on thesame page, that we aretalking about what you thinkis important and you believetoday’s meeting was right foryou. Please let me know if Iget off track, because lettingme know would be thebiggest favor you could do forme.

Let me just take a secondhere to look at this SRS—it’skind of like a thermometerthat takes the temperature ofour meeting here today. Wow,great, looks like we are on thesame page, that we aretalking about what you thinkis important and you believetoday’s meeting was right foryou. Please let me know if Iget off track, because lettingme know would be thebiggest favor you could do forme.

Thanks and ExploringWhat About Below 36 or 9cm?

Thanks and ExploringWhat About Below 36 or 9cm?

Don’t expect specificsor revelations—anyfeedback is a godsend

Is there anything else Icould have done,something I shouldhave done more of orless of, some questionor topic I should haveasked?

Don’t expect specificsor revelations—anyfeedback is a godsend

Is there anything else Icould have done,something I shouldhave done more of orless of, some questionor topic I should haveasked?


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Thankingand Exploring

Thankingand Exploring

Let me quickly look at thisother form here that lets meknow how you think we aredoing. Okay, seems like I ammissing the boat here. Thanksvery much for your honestyand giving me a chance toaddress what I can dodifferently. Was theresomething else I should haveasked you about or shouldhave done to make thismeeting work better for you?What was missing here?

Let me quickly look at thisother form here that lets meknow how you think we aredoing. Okay, seems like I ammissing the boat here. Thanksvery much for your honestyand giving me a chance toaddress what I can dodifferently. Was theresomething else I should haveasked you about or shouldhave done to make thismeeting work better for you?What was missing here?

The Session Rating ScaleOther Responses

The Session Rating ScaleOther Responses

When time an issue, setexpectation that the SRS willincrease over time.

Sometimes: “I don’t know” or“Nobody’s perfect.” Or will rateyou low & never say why, orrate high all the way. It’s all ok.

Continue to leave space forfeedback, to want it, and manyclients will. Even if they don’t,your attention to the alliancewill help. Get points for trying.

When time an issue, setexpectation that the SRS willincrease over time.

Sometimes: “I don’t know” or“Nobody’s perfect.” Or will rateyou low & never say why, orrate high all the way. It’s all ok.

Continue to leave space forfeedback, to want it, and manyclients will. Even if they don’t,your attention to the alliancewill help. Get points for trying.


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The SRSGraceful Acceptance

The SRSGraceful Acceptance

And a willingness to be flexibleusually turn things around.

Clients reporting allianceproblems more likely forsuccess. Lower scores on theSRS should be celebrated.

If clients are comfortableenough to express somethingisn’t right, then you are doingsomething great.

And a willingness to be flexibleusually turn things around.

Clients reporting allianceproblems more likely forsuccess. Lower scores on theSRS should be celebrated.

If clients are comfortableenough to express somethingisn’t right, then you are doingsomething great.

XX

X

X

Now we’re ready to be better therapists,but first we must heed the words of a notedpsychotherapy scholar


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Granted, at firstblush, thesehardly seem likewords fortherapists to liveby—but, as itturns out, theyare.

Sage Psychotherapy Scholar:Mae West?

When I’mgood,I’m verygood,but whenI’m bad,I’m better.

Becoming BetterHelping Every Single Client


When clients are notbenefiting provides theopportunity to do yourbest work—gives youthe possibility of beinghelpful to everyone yousee. Sound too good tobe true? It’s not.

When clients are notbenefiting provides theopportunity to do yourbest work—gives youthe possibility of beinghelpful to everyone yousee. Sound too good tobe true? It’s not.


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Becoming BetterIdentifying Clients Not Responding

Becoming BetterIdentifying Clients Not Responding

When outcome is badin other words, youcan make it better bychanging somethingabout the therapy toturns things around;and if things don’t turnaround, by moving theclient on to a differentprovider or service

When outcome is badin other words, youcan make it better bychanging somethingabout the therapy toturns things around;and if things don’t turnaround, by moving theclient on to a differentprovider or service

Becoming BetterTwo Choices: Not Rocket Science

Becoming BetterTwo Choices: Not Rocket Science

Either the client isimproving or not. If not,the client is at risk.

Engage client in discussionabout progress, and whatshould be done differentlyif there isn’t any.

Keeps clients engaged sothat a new direction can beplanned.

Either the client isimproving or not. If not,the client is at risk.

Engage client in discussionabout progress, and whatshould be done differentlyif there isn’t any.

Keeps clients engaged sothat a new direction can beplanned.


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Becoming BetterWhen I’m Good, I’m Very Good

Becoming BetterWhen I’m Good, I’m Very Good

When ORS scoresincrease, when you’regood, a crucial step tobe very good is helpclients see gains as aconsequence of theirown efforts and makesense of its meaningso repeat in thefuture.

When ORS scoresincrease, when you’regood, a crucial step tobe very good is helpclients see gains as aconsequence of theirown efforts and makesense of its meaningso repeat in thefuture.

Becoming BetterLinking Outcome to Treatment

••See clientsSee clients moremorefrequently when thefrequently when theslope of change isslope of change issteep.steep.

••Begin to space theBegin to space thevisits as the rate ofvisits as the rate ofchange lessens.change lessens.

••See clients as longSee clients as longas there isas there ismeaningful changemeaningful change& they desire to& they desire tocontinue.continue.


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Becoming BetterDoesn’t Mean All Therapy Should Be Brief

Becoming BetterDoesn’t Mean All Therapy Should Be Brief

Au contraire, researchsuggests that more isbetter than less forclients who progressearly & want to continue.

When little or change,however, same dataindicates that therapyshould, indeed, be asbrief as possible.

Au contraire, researchsuggests that more isbetter than less forclients who progressearly & want to continue.

When little or change,however, same dataindicates that therapyshould, indeed, be asbrief as possible.

Involve the client inmonitoring progress & thedecision about what to donext, to elicit his or her ideas& formulate a plan.

The discussion repeated in allmeetings, but later ones gainsignificance and warrantadditional action: Checkpointand Last Chance Discussions.

Involve the client inmonitoring progress & thedecision about what to donext, to elicit his or her ideas& formulate a plan.

The discussion repeated in allmeetings, but later ones gainsignificance and warrantadditional action: Checkpointand Last Chance Discussions.

Becoming BetterWhat to Do NextBecoming BetterWhat to Do Next


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Becoming BetterWhen to Say WhenBecoming Better

When to Say When

Stimulates both clientand therapist tostruggle withcontinuing a processthat is yielding little orno benefit.

To support what isworking & challengewhat is not. Urgencyincreases over time

Stimulates both clientand therapist tostruggle withcontinuing a processthat is yielding little orno benefit.

To support what isworking & challengewhat is not. Urgencyincreases over time

Checkpoint Session:An Opportunity to Be Better

Checkpoint Session:An Opportunity to Be Better

Be transparent—comment about thelack of progress andseek feedback fromthe client about whathe/she thinks it means

Be transparent—comment about thelack of progress andseek feedback fromthe client about whathe/she thinks it means


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Okay, so things haven’t changed sincethe last time we talked. How do youmake sense of that? Should we be doingsomething different here, or should wecontinue on course steady as we go? Ifwe are going to stay on the same track,how long should we go before gettingworried? When will we know when to say“when?”

Okay, so things haven’t changed sincethe last time we talked. How do youmake sense of that? Should we be doingsomething different here, or should wecontinue on course steady as we go? Ifwe are going to stay on the same track,how long should we go before gettingworried? When will we know when to say“when?”

Becoming BetterClient Not Improving

Becoming BetterClient Not Improving

Becoming BetterFirst, the AllianceBecoming BetterFirst, the Alliance

“It doesn’t look like we aregetting anywhere. Let’s goover the SRS to make sureyou are getting exactlywhat you are looking for.”Going thru SRS and elicitingclient responses in detailcan help you & the clientget a better sense of whatmay not be working.

“It doesn’t look like we aregetting anywhere. Let’s goover the SRS to make sureyou are getting exactlywhat you are looking for.”Going thru SRS and elicitingclient responses in detailcan help you & the clientget a better sense of whatmay not be working.


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Checkpoint ConversationFurther Considerations

Checkpoint ConversationFurther Considerations

Worth exploring fit of yourapproach with client’ssensibilities about what needsto happen—the client’s theoryof change.

Ringing true with the client willincrease expectation for changeas well as participation.

Client’s TOC unfolds from aconversation structured by yourcuriosity about the client’sideas, attitudes, andspeculations about change.

Worth exploring fit of yourapproach with client’ssensibilities about what needsto happen—the client’s theoryof change.

Ringing true with the client willincrease expectation for changeas well as participation.

Client’s TOC unfolds from aconversation structured by yourcuriosity about the client’sideas, attitudes, andspeculations about change.

Checkpoint ConversationDo Something DifferentCheckpoint ConversationDo Something Different

Nothing may come of talkabout the alliance. Don’tworry. Making effort helps.

Invite others from supportsystem, use a team or co-therapist, a differentapproach; referral to anothertherapist, religious advisor,or self-help group—whateverseems of value.

Any ideas are implemented,and progress is monitored.

Nothing may come of talkabout the alliance. Don’tworry. Making effort helps.

Invite others from supportsystem, use a team or co-therapist, a differentapproach; referral to anothertherapist, religious advisor,or self-help group—whateverseems of value.

Any ideas are implemented,and progress is monitored.


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Becoming BetterPrecipitous DropsBecoming BetterPrecipitous Drops

Get explanation: Is the droprelated to the reason forservice—a deterioration—oris a recent event holdingsway over the client’srating?

If deterioration, then a redflag, signals the necessity tohave a heart to heart aboutwhat needs to happendifferent to quickly turnthings around.

Get explanation: Is the droprelated to the reason forservice—a deterioration—oris a recent event holdingsway over the client’srating?

If deterioration, then a redflag, signals the necessity tohave a heart to heart aboutwhat needs to happendifferent to quickly turnthings around.

Becoming BetterPotholes Are Different

Becoming BetterPotholes Are Different

Hit a pot hole, etc. Eventshold sway over rating.

If pothole, ask to redolooking at the whole week,related to reasons for tx.

If pothole trumps the orig.reasons for tx, then go withit. Reconnect new issues toORS. Don’t turn life eventsinto therapy issues.

Hit a pot hole, etc. Eventshold sway over rating.

If pothole, ask to redolooking at the whole week,related to reasons for tx.

If pothole trumps the orig.reasons for tx, then go withit. Reconnect new issues toORS. Don’t turn life eventsinto therapy issues.


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Becoming BetterZigzag

Becoming BetterZigzag

Sometimes scores, evenwhen connected to theclient’s problems go up anddown over time—a zigzagpattern.

Of primary interest iswhether there is an upwardor downward trend—backto the basic question: Arethings getting better or not?

Sometimes scores, evenwhen connected to theclient’s problems go up anddown over time—a zigzagpattern.

Of primary interest iswhether there is an upwardor downward trend—backto the basic question: Arethings getting better or not?

Becoming BetterThe Last Chance Discussion


Driving into desertrunning on empty,“last chance for gas.”

Depicts the necessityof stopping anddiscussing theimplications ofcontinuing w/ochange.

Driving into desertrunning on empty,“last chance for gas.”

Depicts the necessityof stopping anddiscussing theimplications ofcontinuing w/ochange.


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Becoming BetterNever the LAST CHANCE

Becoming BetterNever the LAST CHANCE

Doesn’t mean the“last chance” foryour client—butrather the lastchance of a changeplan or pairing. Nolast chance for yourclient—referral canmake thedifference!

Doesn’t mean the“last chance” foryour client—butrather the lastchance of a changeplan or pairing. Nolast chance for yourclient—referral canmake thedifference!

1.What does the client say?2.What have you done

differently?3.What can be done

differently now?4.What other resources can

be rallied?5.Is it time to fail

successfully?

Last Chance ThoughtsThe Longer w/o Change, the Quicker to #5


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All clients can’t benefit. Stilla way to be helpful.

Might have felt like afailure. But when I’m bad,I’m better. Now successfulwhen client achieveschange & when, in theabsence of change, I getout of the way.

All clients can’t benefit. Stilla way to be helpful.

Might have felt like afailure. But when I’m bad,I’m better. Now successfulwhen client achieveschange & when, in theabsence of change, I getout of the way.



At the least, consultation

Referral seriously discussed.

Rarely justified to continuepast typical period.

Rarely is not never. Highlyidiosyncratic & uniquelynegotiated. Keeps us honest,addresses the lack of changetransparently—new for me.

At the least, consultation

Referral seriously discussed.

Rarely justified to continuepast typical period.

Rarely is not never. Highlyidiosyncratic & uniquelynegotiated. Keeps us honest,addresses the lack of changetransparently—new for me.


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Becoming BetterGuard Against Finger Pointing

Becoming BetterGuard Against Finger Pointing

Guard against explainingclient response thrutheoretical filters &folklore— puts us rightback where we havetraditionally been—attributing lack of changeto the client. Client non-response meanssomething else should bedone.

Guard against explainingclient response thrutheoretical filters &folklore— puts us rightback where we havetraditionally been—attributing lack of changeto the client. Client non-response meanssomething else should bedone.

When I’m Bad, I’m BetterFailing Successfully

When I’m Bad, I’m BetterFailing Successfully

Repeat commitment tohelp them achieve goals.

Failure says nothingabout them or theirpotential.

If client wants, meet untilarrangements are made.

But rarely continue withclients who show noimprovement.

Repeat commitment tohelp them achieve goals.

Failure says nothingabout them or theirpotential.

If client wants, meet untilarrangements are made.

But rarely continue withclients who show noimprovement.


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Failing SuccessfullyFailing Successfully

Change of Therapist

Watershed ClientFailing SuccessfullyWatershed Client

Failing Successfully

I believed in PBE, but…

Awakened me to thepitfalls; taught me to failsuccessfully.

Avoid a “chronic” client—the iatrongenic effects ofcontinuing therapy w/obenefit.

ORS allows us to askourselves hard questions.

I believed in PBE, but…

Awakened me to thepitfalls; taught me to failsuccessfully.

Avoid a “chronic” client—the iatrongenic effects ofcontinuing therapy w/obenefit.

ORS allows us to askourselves hard questions.

I wish my helper hadfailed successfully


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Becoming BetterFeedback Is My Compass

Becoming BetterFeedback Is My Compass

Not an uninhabited terrain oftechnical procedures, nor thepredictable path of diagnosis,prescription, & cure. Cannot bedescribed w/o the client &therapist, co-adventurers in ajourney across unchartedterritory. Common factorsprovide landmarks for thisinterpersonal & idiosyncratic trip,& specific models provide well-traveled directions to consider,but feedback provides thecompass, showing the way tothe desired destination.

Not an uninhabited terrain oftechnical procedures, nor thepredictable path of diagnosis,prescription, & cure. Cannot bedescribed w/o the client &therapist, co-adventurers in ajourney across unchartedterritory. Common factorsprovide landmarks for thisinterpersonal & idiosyncratic trip,& specific models provide well-traveled directions to consider,but feedback provides thecompass, showing the way tothe desired destination.

Being BadCan Make You Better

Being BadCan Make You Better

Helps clients you are alreadyeffective with by empoweringchange—helps those notbenefiting by enabling otheroptions and, in absence ofchange, the ability to movethe client on.

When we’re good, we’revery good, but whenwe’re bad, we can beeven better.

Helps clients you are alreadyeffective with by empoweringchange—helps those notbenefiting by enabling otheroptions and, in absence ofchange, the ability to movethe client on.

When we’re good, we’revery good, but whenwe’re bad, we can beeven better.

HeartandSoulofChange

Education

treatment matching

types of treatment

matching alcoholism

alliance cbt

factors common

best predictor of outcome

implicit common factors

journal of studies