LISTENING TO CLIENTS, NOT LABELS

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1 2/16/2015 LISTENING TO CLIENTS, NOT LABELS Outcome-Informed Practice with Children and Families JACQUELINE SPARKS, PH.D. UNIVERSITY OF RHODE ISLAND

2 LISTENING TO CLIENTS, NOT LABELS Outcome-Informed Practice with Children and Families JACQUELINE SPARKS, PH.D. UNIVERSITY OF RHODE ISLAND OUTCOME MANAGEMENT Not a technique Not a model Not a theory PRIVILEGING CLIENTS VOICES... Outcome management is therapeutic work informed by continuous, real-time feedback from clients about their views of progress and the therapeutic alliance.... OVER EXPERT THEORIES AND DIAGNOSES... LISTENING TO CLIENTS, NOT LABELS 1

3 THE DODO BIRD VERDICT With few exceptions, studies (designed to prove the unique effects of a given model) have found no differences Nor have recent metaanalyses The most replicated finding in the psychological literature THE DODO VERDICT: IMPLICATIONS Approaches work because factors common to all So what are the factors? Client Factors: Extra-therapeutic factors, client factors, and unexplained variance. META-ANALYTIC RESEARCH 13% Treatment: 13% of outcome is due to treatment factors (therapist, alliance, technique, etc.) OVER-LAPPING TREATMENT EFFECTS (13%) Feedback (15-31%) Alliance (38-54%) 87% Model/Technique (8%) Wampold, B. (2001). The Great Psychotherapy Debate. New Client York: Extratherapeutic Lawrence Psychotherapy Erlbaum. Therapist Effects (46-69%) Expectancy/Allegiance: Rationale/Ritual (30 -? %) IMPLICATIONS OF COMMON FACTORS You can t know the best approach in advance for the client in front of you! APA DEFINITION OF EBP Evidence-based practice is the integration of the best available research with clinical expertise in the context of client characteristics, culture, and preferences (American Psychologist, May 2006). You can only know that one client at a time. 2

4 Decisions need to be made in collaboration with the client based on the best evidence Most effective when responsive to the client s strengths, cultural context, and preferences. Responses are variable. APA RECOMMENDATIONS Ongoing monitoring of client progress and adjusting as needed is essential. THE GOOD, THE BAD, AND THE UGLY The average treated client is better off than 80% of the untreated sample Not everyone benefits dropouts are a significant problem in routine care, averaging as much as 47%. In a national database of over 6,000 clients averaging 5 sessions of psychotherapy, only 20% improved. PREVENTING DROP-OUT Clients drop out for 2 reasons: counseling is not helping alliance problems not engaged Need to monitor outcome and the alliance! TO THE RESCUE Outcome Management OM has proven track record of improving outcomes OM can provide hard data during and after involvement Clinicians can know how they are doing and can respond immediately to problems WHAT IS OUTCOME MANAGEMENT? Ongoing, real-time comparison of client views of progress with an expected treatment response derived from client characteristics and an anticipated rate of change. The expected treatment response trajectory serves as a yardstick for signaling when change is not occurring as predicted. Clinicians and their clients have an opportunity to discuss such topics as the need to shift focus, re-visit goals, or alter treatment interventions before deterioration or possible dropout. 3

5 THE FOUNDATION OF OM Client s subjective experience of change early in the process the best predictor of success. IMPLICATIONS OF EARLY CHANGE Measure early and often! Client s rating of the alliance the best predictor of engagement and outcome. PCOMS MEASURES: ORS, SRS, CORS Client places a mark on the line that indicates how he or she is doing in each domain Each line is 10 cm in length Score to the nearest millimeter using a 10 cm ruler Add all scores for a total score Given at end of session Client places a mark on the line that indicates how he or she felt the session went Each line is 10 cm in length Score to the nearest millimeter using a 10 cm ruler Add all scores for a total score Discuss if total falls below 36 Ages 6-12 Rates at a 3 rd grade reading level Clinician uses own judgment as to suitability for child/youth 4

6 Under 6 Involves all members of the family, even the youngest Have crayons and locate places to color ready HOW DIFFERENT FROM OTHER OUTCOME MEASUREMENT SYSTEMS Co-constructed with client Goes from general look at client distress to specific representation of client s experience & reason for service Requires nuance & skill in application Feasible ISN T IT GOOD Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), Feedback clients achieved nearly 4x the rate of reliable and significant change compared to TAU (40.8% v. 10.8%); both in couple, 50.5% v. 22.6%. Feedback superiority (2x) maintained at 6 month followup. Divorce and separation rates for feedback couples was 46.2% less than TAU couples. META-ANALYSIS [OF PCOMS] LAMBERT & SHIMOKAWA (2011) Those in feedback group had 3.5 higher odds of experiencing reliable change Those in feedback group had less than half the odds of experiencing deterioration Feedback attained.48 ES Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48,

7 YES, IT IS TIME FOR CLINICIANS TO ROUTINELY MONITOR TREATMENT OUTCOME MICHAEL LAMBERT COOPER, STEWART, SPARKS, & BUNTING (2012) Cohort study of yr. olds; caretaker-228; teacher- 249; 11 counselors; 28 schools Significant reductions in psychological distress; pre-post effect size d = 1.49 on primary outcome measure; 88.7% clinical improvement. 2 fold advantage over children (tx and no-tx) measured on the SDQ (no fb) A SAMHSA EBP BUT DIFFERENT PCOMS is a-theoretical & therefore additive to any therapeutic orientation including other EBPs. PCOMS applies to clients of all diagnostic categories Southwest Behavioral Health Public Behavioral Health SBHS, Multicultural PBH Center With a $70 Million Budget Reese, Duncan, Bohanske, Owen, & Minami (2014): PBH achieved outcomes comparable to RCTs of depression and feedback using PCOMS. THE HOW-TO S THE VALUE OF AN IDEA LIES IN THE USING OF IT. THOMAS EDISON Introducing the ORS/CORS Integrating the ORS/CORS into the meeting Finding out is risky; what if you find out that you don t have the outcomes you want? The only way we improve is through feedback. It takes courage. But so does walking in a room with someone in distress. 6

8 COUNSELOR VARIABILITY FEEDBACK IMPROVES OUTCOMES Norway: 9 of 10 got better outcomes Feedback raised effectiveness of the lower ones to their more successful colleagues. Counselors in low effectiveness group became the BEST with feedback! INTRODUCING MEASURES WITH FAMILIES (WHEN CHILD/ADOLESCENT IS PRESENTED AS THE PROBLEM) Child/adolescent fills out ORS or CORS, depending on age or maturity level. Parent/caretaker fills out ORS or CORS with their view of how they see their child or adolescent doing. INTRODUCING THE ORS/CORS Describe as routine; mention when it is used Provide rationale/why important Your voice is very important Your scores will serve as a benchmark for measuring progress; committed to you reaching their goals Give guidance as needed SAMPLE SCRIPTS (BEST TO USE YOUR OWN WORDS) To adolescent: Here is a form that only takes a few minutes that we ll be using these every time we meet. If you could just fill it out based on how you feel you are doing in these areas of your life. This helps me track how you re doing and helps us know if our work together is being helpful, and that is very important to me. In a way this is keeping track of us both. I use this because I want to make sure that I m being helpful. Would you be willing to do that? Great! Thanks! To a child: Here is that paper with smiley and frowny faces I mentioned to you. This form lets us know how you re doing, how things are going for you while we work together. It lets me know if I am being helpful. Most kids find it to be pretty easy to do. Would you like to give it a try? Great! PARENT/CARETAKER SAMPLE SCRIPT And here s a form that you can fill out to let me know how you see [child/adolescent s name] doing. You know your child a lot better than anyone. This way, we can track what we re doing here and make sure that you see progress. If not, we can talk about what we need to do to get things moving in the right direction. Does that sound okay to you? BE PREPARED 7

9 LOOKING LIKE A KLUTZ WE ARE ALL BOZOS ON THIS BUS Score the marks. Need a 10 cm ruler. Many will not try fear of looking like a bozo. Worry about measuring marks & adding the scores. 4 marks & 4 scores, not regression equations. Practice until you feel confident. But, it s okay to look inept from time to time with clients. And believe me, however you do it won t be as bad as I ve done it. The cutoff status Shared understanding Create focus INTEGRATING THE ORS/CORS THREE CONSIDERATIONS FOR STARTING THE INTERVIEW Ages 6-12 Clinical Cutoff: Children (6-12) = 32 Adolescents (13-17) = 28 Ages Clinical Cutoff: Caretaker Child (6-12) = 28 Caretaker Adolescent (13-17) = 28 CUTOFF STATUS Where the client s scores are in relation to the clinical cutoff is the first chance to make meaning of the measure with the client s life experience. Below 28/32, child/adolescent and caretaker scores are within the clinical range. Scoring more like people in distress and wanting something to change The slope of change decreases when clients score close to the clinical cutoff. SHARED UNDERSTANDING Comment on the client s scores Connect the scores to the client s described experience At that moment, everyone knows what the marks mean and how success will be measured Get a good read so that the scores are meaningful 8

10 Your scores are below the line here that separates people who decide to come in for counseling and talk to someone and those who don t. Looks like you want something different in your life. Does that make sense to you? So when this score goes up, that will tell us you re moving in the right direction? How could you use this information to begin or focus the session? Age Total = 28 WHEN SCORES ARE SIMILAR Comment on it as a strength Highlight the commonality Use it as a stepping stone to establish mutual goals Different scores are concrete, visible opportunities to inquire about everyone s unique perceptions and beliefs. WHEN SCORES DIFFER DON T WORRY, BE HAPPY 9

11 PRACTICE Describe ORS as: routine/how often used how it will be helpful (serves as a benchmark and makes sure their voice is in the lead) give guidance as needed Comment on: cutoff and what that means your interpretation to make sure there is a common understanding Use scores to: lead in into and focus the session identify biggest area/s of concern and strengths HIGH SCORES BEING INFORMED BY THE ORS/SRS Look for any deviation down Make a comment If high flat-lined always, may be accurate Or, may be inaccurate If inaccurate, continue to use without putting in database Scores from meeting to meeting serve as benchmarks for whether progress is being made. Graphs facilitate sharing trajectories THE SRS Attend to the age and developmental level of youth in a family Communicate your sincere desire to know what they think Communicate that this is how to get the best outcome Offer any assistance needed Thank the client for any and all feedback Inquire about what was missing for any mark that even slightly dips below a nine Inquire about what it would take to move it up a notch 10

12 PCOMS DOES PROMOTE A SET OF VALUES Client privilege in determining the benefit of services & in all decisions that affect care including intervention preferences An expectation of recovery An attention to those common factors that cut across all models that account for change An appreciation of social justice in the provision of care or what is called client directed out informed practices (CDOI) VOICE & CHOICE Youth have a right to be heard Youth have a right to direct the help they are receiving Youth have a right to choices for their identity and their future that is much more than a diagnosis MORE INFORMATION ORS/CORS RELIABILITY AND VALIDITY Duncan, B. L. (2012). The Partners for Change Outcome Management System: The Heart and Soul of Change Project. Canadian Psychology, 53(2), DOI: /a Duncan, B., & Sparks, J. (2014). Getting better with couples, families, and youth. In B. L. Duncan, On becoming a better therapist: Evidence-based practice one client at a time (pp ). Washington, DC: American Psychological Association. Internal consistency for the CORS is.93 for adolescents and.84 for children (coefficient alpha estimates; Duncan et al., 2006) As an indicator of treatment progress, ORS/CORS scores are sensitive to change for clinical samples yet stable over time for nonclinical samples (Bringhurst et al., 2006; Duncan et al., 2006; Miller et al., 2003). Statistically significant differences between pretreatment and posttreatment ORS scores support the ORS/CORS s sensitivity to change (Duncan et al., 2006; Miller et al., 2003) 11

13 SRS PSYCHOMETRICS Evidence of concurrent validity.49 correlation with the Helping Alliance Questionnaire. Independent analysis (Campbell & Hemsley, 2009).63 correlation between the SRS and Working Alliance Inventory. Significant correlation with Therapist Satisfaction Scale (Hafkenscheid, 2009). Correlates with outcome similarly to other alliance measures (.27); Internal consistency in the 90 s 12

14 PRACTICE Describe ORS as: routine/how often used how it will be helpful (serves as a benchmark and makes sure their voice is in the lead) give guidance as needed Comment on: cutoff and what that means your interpretation to make sure there is a common understanding Use scores to: lead in into and focus the session identify biggest area/s of concern and strengths 1

15 Outcome Rating Scale (ORS) Name Age (Yrs): Sex: M / F Session # Date: Who is filling out this form? Please check one: Self Other If other, what is your relationship to this person? Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels. If you are filling out this form for another person, please fill out according to how you think he or she is doing. Individually (Personal well-being) Interpersonally (Family, close relationships) Socially (Work, school, friendships) Overall (General sense of well-being) The Heart and Soul of Change Project , Scott D. Miller and Barry L. Duncan

16 Session Rating Scale (SRS V.3.0) Name Age (Yrs): ID# Sex: M / F Session # Date: Please rate today s session by placing a mark on the line nearest to the description that best fits your experience. Relationship I did not feel heard, understood, and respected. We did not work on or talk about what I wanted to work on and talk about. The therapist s approach is not a good fit for me. There was something missing in the session today. Goals and Topics Approach or Method Overall I felt heard, understood, and respected. We worked on and talked about what I wanted to work on and talk about. The therapist s approach is a good fit for me. Overall, today s session was right for me. The Heart and Soul of Change Project , Scott D. Miller, Barry L. Duncan, & Lynn Johnson

17 Child Outcome Rating Scale (CORS) Name Age (Yrs): Sex: M / F Session # Date: Who is filling out this form? Please check one: Child Caretaker If caretaker, what is your relationship to this child? How are you doing? How are things going in your life? Please make a mark on the scale to let us know. The closer to the smiley face, the better things are. The closer to the frowny face, things are not so good. If you are a caretaker filling out this form, please fill out according to how you think the child is doing. Me (How am I doing?) Family (How are things in my family?) School (How am I doing at school?) Everything (How is everything going?) The Heart and Soul of Change Project , Barry L. Duncan, Scott D. Miller, & Jacqueline A. Sparks

18 Child Session Rating Scale (CSRS) Name Age (Yrs): Sex: M / F Session # Date: How was our time together today? Please put a mark on the lines below to let us know how you feel. did not always listen to me. What we did and talked about was not really that important to me. I did not like what we did today. Listening How Important What We Did listened to me. What we did and talked about were important to me. I liked what we did today. I wish we could do something different. Overall I hope we do the same kind of things next time. The Heart and Soul of Change Project , Barry L. Duncan, Scott D. Miller, Jacqueline A. Sparks, & Lynn D. Johnson

19 Young Child Outcome Rating Scale (YCORS) Name Age (Yrs): Sex: M / F Session # Date: Choose one of the faces that shows how things are going for you. Or, you can draw one below that is just right for you. The Heart and Soul of Change Project , Barry L. Duncan, Scott D. Miller, Andy Huggins, and Jacqueline A. Sparks

20 Young Child Session Rating Scale (YCSRS) Name Age (Yrs): Sex: M / F Session # Date: Choose one of the faces that shows how it was for you to be here today. Or, you can draw one below that is just right for you. The Heart and Soul of Change Project , Barry L. Duncan, Scott D. Miller, Andy Huggins, & Jacqueline Sparks