UsingPCOMSwithYouthandFamilies:Parkinson

https://heartandsoulofchange.com September, 2013

Pamela Parkinson [email protected] 1

The Heart and Soul of Change The Heart and Soul of Change

Delivering WhatDelivering WhatDelivering WhatDelivering WhatDelivering What Delivering What

Works With KidsWorks With Kids

and Familiesand Families

Delivering What Delivering What

Works With KidsWorks With Kids

and Familiesand Families

Pamela Parkinson, Ph.D., LCSW [email protected]

Developer: Barry Duncan, Psy.D.

Website: Heartandsoulofchange.com

Pamela Parkinson, Ph.D., LCSW [email protected]

Developer: Barry Duncan, Psy.D.

Website: Heartandsoulofchange.com

Welcome!Welcome!

Who am I?Who am I?



I am a licensed Clinical Psychologist and a Licensed Clinical Social Worker in the S.F. Bay Area of California

I am a licensed Clinical Psychologist and a Licensed Clinical Social Worker in the S.F. Bay Area of CaliforniaArea of California.

I run the Bay Area Family Institute of Training and travel around helping individuals, programs, and organizations get unstuck in their work with kids and families.

Area of California. I run the Bay Area Family Institute of

Training and travel around helping individuals, programs, and organizations get unstuck in their work with kids and families.

I specialize in training/consultation using the one-way mirror.

I started off working as a residential counselor in intensive residential treatment.

I specialize in training/consultation using the one-way mirror.

I started off working as a residential counselor in intensive residential treatment.

The Kids and Families Struggling the Most!

The Kids and Families Struggling the Most!

My whole career has focused on kids in the f t t th j il j ti t

My whole career has focused on kids in the f t t th j il j ti tfoster care system, the juvenile justice system, the mental health system and those labeled as emotionally disturbed within the Special Education System.

These are the “high end” kids that are referred

foster care system, the juvenile justice system, the mental health system and those labeled as emotionally disturbed within the Special Education System.

These are the “high end” kids that are referredThese are the high end kids that are referred to the private non-profit CBO’s who attempt to do a good job with few resources and very little funding. These are the kids we will be talking about today.

These are the high end kids that are referred to the private non-profit CBO’s who attempt to do a good job with few resources and very little funding. These are the kids we will be talking about today.



Here are some Questions that I will focus on today regarding PCOMS in our work with Kids

and Families!

Here are some Questions that I will focus on today regarding PCOMS in our work with Kids

and Families!

Does everyone in the family need to Does everyone in the family need to Does everyone in the family need to complete the ORS? It can be so chaotic!

How do I know where to start reviewing the scores on the ORS when they are all low? E i ll i h l f f il b i

Does everyone in the family need to complete the ORS? It can be so chaotic!

How do I know where to start reviewing the scores on the ORS when they are all low? E i ll i h l f f il b i Especially with a lot of family members in the room.Especially with a lot of family members in the room.

More Questions!More Questions!

Should I start in mid-treatment with these Should I start in mid-treatment with these tools? If feels like I should only use these from the beginning of treatment.

How do I handle all high scores from kids and even all 10’s?

tools? If feels like I should only use these from the beginning of treatment.

How do I handle all high scores from kids and even all 10’s?and even all 10 s?

Is it helpful to include some of the referring folks like County Social Workers, Probation Officers, Teachers, etc.? How?

and even all 10 s? Is it helpful to include some of the referring

folks like County Social Workers, Probation Officers, Teachers, etc.? How?



More QuestionsMore Questions

What do I do with the ORS during the summer if school is the big issue?

What do I do with the ORS during the summer if school is the big issue?

I am not a therapist so can I use these Tools? I am not a therapist so can I use

these Tools?

Your Questions!Your Questions!

More Questions can be asked inMore Questions can be asked inMore Questions can be asked in the last 10-15 minutes of this Webinar so write them down so you don’t forget!

More Questions can be asked in the last 10-15 minutes of this Webinar so write them down so you don’t forget!If we don’t get to them, email me and I will answer them!If we don’t get to them, email me and I will answer them!



Here we go!Here we go!

As you all know, PCOMS stands As you all know, PCOMS stands for:

Partners for Change Outcome Management

for:

Partners for Change Outcome ManagementOutcome Management

SystemOutcome Management

System

Why do I Like PCOMS?Why do I Like PCOMS?

Tons of evidence that it helps clients to Tons of evidence that it helps clients to have successful outcomes!

Strength-based, client-directed, outcome-informed.

Can be used with ANY theoretical way of

have successful outcomes! Strength-based, client-directed, outcome-

informed. Can be used with ANY theoretical way ofCan be used with ANY theoretical way of

thinking so you don’t have to abandon what you love doing (CBT, family systems, psychodynamic, humanistic, etc., etc.).

Can be used with ANY theoretical way of thinking so you don’t have to abandon what you love doing (CBT, family systems, psychodynamic, humanistic, etc., etc.).



Why do I Like PCOMS?Why do I Like PCOMS?

Works for clients of all agesWorks for clients of all agesWorks for clients of all ages, diagnoses, ethnicities, etc.: Barry calls this “one size fits all” and I call it your “umbrella policy”.

Works for clients of all ages, diagnoses, ethnicities, etc.: Barry calls this “one size fits all” and I call it your “umbrella policy”.Very affordableCompatible with other EBP’s so it can overlay with anything!

Very affordableCompatible with other EBP’s so it can overlay with anything!

The Importance of Client FeedbackThe Importance of Client Feedback to Positive to Positive OutcomesOutcomes

The Importance of Client FeedbackThe Importance of Client Feedback to Positive to Positive OutcomesOutcomes

Whether an approach is a good fit for Whether an approach is a good fit for a client can only be determined by the client’s response to what is delivered.

It is the client’s feedback regarding progress in therapy (ORS) and the

a client can only be determined by the client’s response to what is delivered.

It is the client’s feedback regarding progress in therapy (ORS) and theprogress in therapy (ORS) and the quality of the alliance (SRS) that will tell us if what we are doing is helpful to the client!

progress in therapy (ORS) and the quality of the alliance (SRS) that will tell us if what we are doing is helpful to the client!



Cli tCli t’’ ti f thti f th

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

••ClientClient ss rating of the rating of the alliancealliance is the best predictor is the best predictor of engagement and of engagement and outcome.outcome.

••ClientClient’’ss subjectivesubjectiveClientClient ss subjective subjective experience of change experience of change early early in the process in the process is the best is the best predictor of success for any predictor of success for any particular pairing.particular pairing.

Who drops out?

Reminder about the Trajectory of Change

A

B

•The bulk of change occurs sooner rather than

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

rather than later



Some clients do take longer, but the mythology never diesdies

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

Note that even for the

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

clients who take longer, change starts early…just is flatter

It Just Makes SenseIt Just Makes Sense

Since early change and the client’s bj ti i f th lli

Since early change and the client’s bj ti i f th lli subjective experience of the alliance,

predict treatment outcome, it seems to make sense that having an early warning system in place could be very helpful!

subjective experience of the alliance, predict treatment outcome, it seems to make sense that having an early warning system in place could be very helpful!system in place could be very helpful!

Maybe we can identify clients at risk of dropping out and not benefitting from services!

system in place could be very helpful!

Maybe we can identify clients at risk of dropping out and not benefitting from services!



PCOMS provides us with this Early Warning System

PCOMS provides us with this Early Warning System

When we see thatWhen we see thatWhen we see that outcome is bad, you can make it better by changing something about

When we see that outcome is bad, you can make it better by changing something aboutsomething about the work to turn things around!

something about the work to turn things around!

Here are our Early Warning System Tools

Here are our Early Warning System Tools

ORS Outcome RatingORS Outcome RatingORS – Outcome Rating Scale

ORS – Outcome Rating Scale

SRS – Session Rating Scale

SRS – Session Rating Scale



••Give at theGive at the

Becoming BetterMeasuring Outcome

Becoming BetterMeasuring Outcome

••Scored to the Scored to the nearest millimeter.nearest millimeter.

••Add the four Add the four scales togetherscales together

••Give at the Give at the beginning of the beginning of the visit; Client visit; Client places a mark places a mark on the line.on the line.

••Each line 10 Each line 10 (100 ) i(100 ) i

scales together scales together for the total score.for the total score.

cm (100 mm) in cm (100 mm) in length.length.

•Reliable, valid, feasible

CORSCORS



•Under 6

•Involves all members of the family even thefamily, even the youngest

•Have crayons and places to color ready

Children and AdolescentsClinical Cutoff

Children and AdolescentsClinical Cutoff

The dividing line The dividing line between a clinical & non-clinical population for adults (25) For children Kids Adolescents (25). For children (32); adolescents (28); caregivers (28).

Kids Adolescents& Caregivers



Kid t lf d lt tKid t lf d lt t

Who, What, When, Where,& Why

Kid rates self; adults rate kid; siblings rate themselves

Spoiler Alert! Sometimes Th A B t M t

Kid rates self; adults rate kid; siblings rate themselves

Spoiler Alert! Sometimes Th A B t M tThey Agree But Most Times They Don’t!

When They Don’t Agree, Don’t Sweat It!

They Agree But Most Times They Don’t!

When They Don’t Agree, Don’t Sweat It!

Some Points to be Aware of with the ORS and CORS

Some Points to be Aware of with the ORS and CORS

Little kids (YCORS) have no scores to input as d t h till i th th f

Little kids (YCORS) have no scores to input as d t h till i th th fdata, however, we still give them the form because it is good clinical work.

Some kids will not understand the form, despite your best efforts to help them with it. In these rare cases, you would continue giving them the

data, however, we still give them the form because it is good clinical work.

Some kids will not understand the form, despite your best efforts to help them with it. In these rare cases, you would continue giving them therare cases, you would continue giving them the ORS/CORS but you would not enter their data.

We are lucky that, with kids, we have another source of data: the caregivers.

rare cases, you would continue giving them the ORS/CORS but you would not enter their data.

We are lucky that, with kids, we have another source of data: the caregivers.



More Points to be Aware of with the ORS and CORS

More Points to be Aware of with the ORS and CORS

If an older kid wants to do the CORS or a younger If an older kid wants to do the CORS or a younger kid is insulted by the faces and wants to do the ORS, this is fine.

While this is usually not an issue, if it becomes one, go with the flow.

kid is insulted by the faces and wants to do the ORS, this is fine.

While this is usually not an issue, if it becomes one, go with the flow.

Since the scoring is the same, it does not matter, however, your cut-off scores will still be those for the actual age of the child/youth regardless of which form they complete.

Since the scoring is the same, it does not matter, however, your cut-off scores will still be those for the actual age of the child/youth regardless of which form they complete.

The Session Rating Scale Measuring the AllianceThe Session Rating Scale Measuring the Alliance

••Give at the end Give at the end of session;of session;

••Score in cm to Score in cm to the nearest mm;the nearest mm;

••Each line 10 cm Each line 10 cm in length;in length;

•Reliable, valid, feasible

••Discuss with Discuss with client anytime client anytime total score falls total score falls belowbelow 3636





Using PaperGraphing: A Helpful Visual

Using PaperGraphing: A Helpful Visual

Adds a visual component another way

Adds a visual component another waycomponent—another way to focus treatment

At a glance tells the story of the client’s progress. ll d f

component—another way to focus treatment

At a glance tells the story of the client’s progress. ll d f Allows you to dispense of

the previous measures. Allows you to dispense of

the previous measures.

•Indispensable with youth and families.

Using Graphs With Families

families.

•Can comment on other’s scores in relation to own

•Invites family discussion about the next steps

•A visual indication of the need •A visual indication of the need for changing approach, continuing, or ending.

•You can let them plot their own scores in different colors. Very interactive!



Let’s Address Those Questions!Let’s Address Those Questions!

The thing that I find most interesting about MOST of the questions that folks ask is that

The thing that I find most interesting about MOST of the questions that folks ask is thatMOST of the questions that folks ask is that they already know the answers!

You have skills and already do good work so why not show it?! You also want to improve, of course!

MOST of the questions that folks ask is that they already know the answers!

You have skills and already do good work so why not show it?! You also want to improve, of course!

Before you ask your question at the end of the Webinar, see if you can answer it using your own clinical judgment. I bet you can!

Before you ask your question at the end of the Webinar, see if you can answer it using your own clinical judgment. I bet you can!

A Simple ExampleA Simple Example

Let’s take this question: Should I start in mid-treatment withLet’s take this question: Should I start in mid-treatment with Should I start in mid treatment with

these tools? If feels like I should only use these from the beginning of treatment. I bet that you would know how to introduce anything

meaningful that might be helpful for your clients into k t i t ld d thi i th

Should I start in mid treatment with these tools? If feels like I should only use these from the beginning of treatment. I bet that you would know how to introduce anything

meaningful that might be helpful for your clients into k t i t ld d thi i th your work at any point so you would do this in the same

way with PCOMS!

If the scores are above the cutoff, use the tools but don’t enter the data.

your work at any point so you would do this in the same way with PCOMS!

If the scores are above the cutoff, use the tools but don’t enter the data.



PCOMS does not replace your work!

PCOMS does not replace your work!

It enhances your work by keeping you focused It enhances your work by keeping you focused y y p g yon the most important aspects of the work! Aspects of which you are already aware !

It is meant to help you get to where you and the client are headed so don’t be distracted or confused by the tools

y y p g yon the most important aspects of the work! Aspects of which you are already aware !

It is meant to help you get to where you and the client are headed so don’t be distracted or confused by the toolsconfused by the tools.

Nothing about PCOMS derails the treatment or interferes with it. It is to help you and the client do what you are trying to do anyway!

confused by the tools. Nothing about PCOMS derails the treatment or

interferes with it. It is to help you and the client do what you are trying to do anyway!

Does everyone in the family need to complete them? It can be so chaotic!Does everyone in the family need to

complete them? It can be so chaotic!

Yes, administer them every time you meet Yes, administer them every time you meet in most settings.

It is important for everyone to be included– it is a family session and the balanced lli i i f il k!

in most settings.

It is important for everyone to be included– it is a family session and the balanced lli i i f il k! alliance is necessary in family work!

Also, remember that doing anything new takes a little practice.

alliance is necessary in family work!

Also, remember that doing anything new takes a little practice.



Chaos ContinuedChaos Continued

Don’t worry about the time it takes to give Don’t worry about the time it takes to give out the tools or your scoring. Just talk with the family about what you are doing and maybe ask their help: measuring or plotting their own scores on a graph etc

out the tools or your scoring. Just talk with the family about what you are doing and maybe ask their help: measuring or plotting their own scores on a graph etcplotting their own scores on a graph, etc.plotting their own scores on a graph, etc.

Into the home, Into the ChaosInto the home, Into the Chaos

Believe it or not, this can actually help in chaotic situations which we experience all the

Believe it or not, this can actually help in chaotic situations which we experience all the chaotic situations, which we experience all the time in work with families.

Using the ORS can help create a kind of focused space for families. It sets the stage f h i f i l i h

chaotic situations, which we experience all the time in work with families.

Using the ORS can help create a kind of focused space for families. It sets the stage f h i f i l i h for the importance of our special time together and family members find it interesting. After all, it is about their opinions and observations so they will like it.

for the importance of our special time together and family members find it interesting. After all, it is about their opinions and observations so they will like it.



Chaos ContinuedChaos ContinuedSpread the scored forms out on the kitchen

table or the floor, or wherever, so that Spread the scored forms out on the kitchen

table or the floor, or wherever, so that everyone can see them together. Doing this creates a focus and communicates that this is a collaborative process in which everyone has an important role and the clinician is not the

everyone can see them together. Doing this creates a focus and communicates that this is a collaborative process in which everyone has an important role and the clinician is not the an important role and the clinician is not the holder of some kind of private information.

Review them all briefly but you can focus on the IP and the caregiver’s ORS for data input.

an important role and the clinician is not the holder of some kind of private information.

Review them all briefly but you can focus on the IP and the caregiver’s ORS for data input.

Chaos ContinuedChaos Continued

Remember, all that the ORS does is help to identify “ ”

Remember, all that the ORS does is help to identify “ ”better what is already “in the room”. It does not

create what is happening in the room, or make it worse, it focuses and contains the issues so that we are less likely to “miss them” in the chaos.

better what is already “in the room”. It does not create what is happening in the room, or make it worse, it focuses and contains the issues so that we are less likely to “miss them” in the chaos.

The ORS gives everyone a voice. If they have some scores in which they agree, this is wonderful.

If not, it is important to get their differences out “on the table” so why not have a tool to help with this?

The ORS gives everyone a voice. If they have some scores in which they agree, this is wonderful.

If not, it is important to get their differences out “on the table” so why not have a tool to help with this?



How do I know where to start reviewing the scores on the ORS when they are all low? Especially with a large family in the room!

It can feel a bit overwhelming especially if

How do I know where to start reviewing the scores on the ORS when they are all low? Especially with a large family in the room!

It can feel a bit overwhelming especially if It can feel a bit overwhelming especially if all the scores are quite low.

I like to start with the lowest score. Since these 4 domains are not discrete entities

It can feel a bit overwhelming especially if all the scores are quite low.

I like to start with the lowest score. Since these 4 domains are not discrete entities and distress is what ties them together, talking about one usually spills into all of them.

and distress is what ties them together, talking about one usually spills into all of them.

Low Scores (Con’t.)

If they have all indicated low scores, this


If they have all indicated low scores, this is a strength in the family because they are in agreement about the distress, or pain, that they are in even if their reasons for the distress are different (and you can

is a strength in the family because they are in agreement about the distress, or pain, that they are in even if their reasons for the distress are different (and you can for the distress are different (and you can BET that they ARE).for the distress are different (and you can BET that they ARE).




Look for ways to help folks experience each th ’ i f di t i iti


Look for ways to help folks experience each th ’ i f di t i iti other s expression of distress, in a positive

direction. For example, a caregiver might indicate their lowest score as 3.4 in the family domain and the kid’s lowest score could be

other s expression of distress, in a positive direction. For example, a caregiver might indicate their lowest score as 3.4 in the family domain and the kid’s lowest score could be 8.5. Seemingly, these would be very different opinions on how things are going. However, have they both selected this as the lowest domain? If so, this could be a place to start.

8.5. Seemingly, these would be very different opinions on how things are going. However, have they both selected this as the lowest domain? If so, this could be a place to start.



Wait a minute! This is one that you know the Wait a minute! This is one that you know the answer to! Often, at first, kids will say that everything is perfect and they have no problems.

Just handle this in the same way you would without an ORS.

answer to! Often, at first, kids will say that everything is perfect and they have no problems.

Just handle this in the same way you would without an ORS.

First, don’t challenge them! Acknowledge that they are indicating that they are “just fine”. Let them save face!

First, don’t challenge them! Acknowledge that they are indicating that they are “just fine”. Let them save face!



All high scores and 10’s (con’t.)All high scores and 10’s (con’t.)

If the scores are all high, but not all 10’s, start with the lowest score (maybe it is 9 2) and find out more

If the scores are all high, but not all 10’s, start with the lowest score (maybe it is 9 2) and find out more the lowest score (maybe it is 9.2) and find out more about it and what would make it be a 9.3.

If they are all 10’s, just reflect this. Remember, the number just reflects what the kid would say anyway so don’t worry about it

the lowest score (maybe it is 9.2) and find out more about it and what would make it be a 9.3.

If they are all 10’s, just reflect this. Remember, the number just reflects what the kid would say anyway so don’t worry about it so don t worry about it.

Now, use your very well honed and creative skills to facilitate a therapeutic process that will allow folks to speak from the heart.

so don t worry about it. Now, use your very well honed and creative skills to

facilitate a therapeutic process that will allow folks to speak from the heart.

All high scores and 10’s (con’t.)All high scores and 10’s (con’t.)

When the kid then opens up in this way, they When the kid then opens up in this way, they When the kid then opens up in this way, they will often be able to talk about something they would like to be different, refer back to the ORS and let them reflect it on the form. They can change their mark!

When the kid then opens up in this way, they will often be able to talk about something they would like to be different, refer back to the ORS and let them reflect it on the form. They can change their mark!can change their mark!can change their mark!



Is it helpful to include some of the referring folks like County Social Workers, Probation Officers,

Teachers, etc.? How?

Is it helpful to include some of the referring folks like County Social Workers, Probation Officers,

Teachers, etc.? How?

Definitely! In fact, they will be impressed Definitely! In fact, they will be impressed that you are looking so closely at how THEY see the issues.

This also gives you a chance to help them understand how these tools are used and

that you are looking so closely at how THEY see the issues.

This also gives you a chance to help them understand how these tools are used and how it is going to help you to work in a manner that is likely to increase positive outcomes.

how it is going to help you to work in a manner that is likely to increase positive outcomes.

What do I do with the ORS School Scale over the summer if school is a big issue?

What do I do with the ORS School Scale over the summer if school is a big issue?

Remember, the School scale on the CORS parallels the corresponding "Socially" item on the ORS—The School

Remember, the School scale on the CORS parallels the corresponding "Socially" item on the ORS—The School p g yscale covers the child's social world including peer relationships, academics, and behavior. Thus, over the summer, it will reflect the child’s or caregiver’s perceptions about their peer friendships and social-based activities that they are involved in over the summer: jobs

p g yscale covers the child's social world including peer relationships, academics, and behavior. Thus, over the summer, it will reflect the child’s or caregiver’s perceptions about their peer friendships and social-based activities that they are involved in over the summer: jobs activities that they are involved in over the summer: jobs, lessons, sports, scouts, church groups, things like that.

However, always check with the child after any ratings are completed to make sure that we are clear on what the mark means to the child.

activities that they are involved in over the summer: jobs, lessons, sports, scouts, church groups, things like that.

However, always check with the child after any ratings are completed to make sure that we are clear on what the mark means to the child.



ORS School Scale (Con’t.)ORS School Scale (Con’t.)

In my world, it is typical that most kids struggle in In my world, it is typical that most kids struggle in more than one domain and really need support over the summer so that they can get off to a good start in the next school year.

Thus, the scale would represent the ongoing work

more than one domain and really need support over the summer so that they can get off to a good start in the next school year.

Thus, the scale would represent the ongoing work done to address the social relationships outside of school in the context of what happens over the summer.

done to address the social relationships outside of school in the context of what happens over the summer.

ORS School Scale (Con’t.)ORS School Scale (Con’t.)

However, If the struggle is academic or However, If the struggle is academic or However, If the struggle is academic or behavioral issues that are strictly related to school (which I have found to be quite rare), then have the child rate where he or she was when the school year ended as a starting

However, If the struggle is academic or behavioral issues that are strictly related to school (which I have found to be quite rare), then have the child rate where he or she was when the school year ended as a starting was when the school year ended as a starting place. Then connect what can be done over the summer to continue to address these concerns.

was when the school year ended as a starting place. Then connect what can be done over the summer to continue to address these concerns.



I am not a therapist so can I use these Tools?

I am not a therapist so can I use these Tools?

This is sooooo important! Since most service id i th fi ld NOT th i t b t

This is sooooo important! Since most service id i th fi ld NOT th i t b t providers in the field are NOT therapists, but

offer just as important services to clients, it would be extremely important for anyone doing direct service to use these tools!

providers in the field are NOT therapists, but offer just as important services to clients, it would be extremely important for anyone doing direct service to use these tools!

There is only one place that uses the word therapist (Approach/Method domain on the SRS) and you can easily use your own title.

There is only one place that uses the word therapist (Approach/Method domain on the SRS) and you can easily use your own title.

Your Questions?Your Questions?Your Questions?Your Questions?

UsingPCOMSwithYouthandFamilies:Parkinson

Health & Medicine

e i ll

high end kids

inmore questions

family need

questionsmore questions

high scores

juvenile justice system

mental health system