Psychosocial Services The Good

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1 The Partners for Change Outcome Management System Evidence Based Practice One Client at a Time What s Up: PCOMS Research, Predictors, Implications 1. Research-proven strategy to address the problems of psychosocial services 2. Incorporates known predictors of ultimate outcome Barry Duncan, Psy.D. pcoms.com heartandsoulofchange.com betteroutcomesnow.com 3. Implications for Policy PCOMS at a Glance Psychosocial Services The Good Study after study, and studies of studies show the average treated client is better off than 80% of the untreated sample. Psychosocial Services The Bad Drop out rates average 47% Providers vary a lot Provider Differences Incredible Variation Among Providers TDCRP: top third psychiatrists giving placebo bested bottom third giving g meds; clients of best counselors improve 50% more & dropped out 50% less; meds useful for clients of more effective, not for less-effective McKay, K., Imel, Z., & Wampold, B. (2006). Psychiatrist effects in the psychopharmalogical treatment of depression. Journal of Depressive Disorders, 92, betteroutcomesnow.com 1

2 More Bad: Public Behavioral Health Less than a Third Benefit Hansen, N., Lambert, M., Forman, E. (2002). The psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9, Reported a combined reliable and clinically significant change rate in everyday clinical practice just 29.1%. Over 70% not helped And the Ugly Providers Don t Know Sapyta, J., Riemer, M., & Bickman, L. Feedback to clinicians: Theory, research, and practice. Journal of Clinical Psychology: In Session, 61, Walfish, S., McAlister, B., O Donnell, P., & Lambert, M. (2012). An investigation of self-assessment bias in mental health providers. Psychotherapy Reports, 110(2), 1-6. doi: / % range Graded their effectiveness, A+ to F 67% said A or better; none rated below average; Another study: 85% of their clients improve & 90% saw themselves as above the 75th percentile. Providers don t know how effective they are No More Head in the Sand Despite overall efficacy, dropouts a problem, not everyone benefits, providers vary significantly and don t have a clue about effectiveness, and outcomes in many settings are dismal. Problems Spurred Interest in Quality Improvement Strategies Primary Approach Has Been Transporting Evidence Based Treatments Problems with Transporting EBTs Dodo Bird Verdict Cost and Practicality Everybody has won and all must have prizes. Cost and Practicality Doesn t Make Cents Cost of Implementing EBT; VA 20 million Practicality Given Staff Turnover, Fidelity Implementing an EBT for Every Diagnoses Over 150 EBTs and Over 400 Diagnoses betteroutcomesnow.com 2

3 No More Head in the Sand The Primary Quality Improvement Strategy Has Big Problems. To The Rescue, Another QI Strategy Continuous Client Feedback: PCOMS The ORS The SRS Download free working copies at: pcoms.com or heartandsoulofchange.com Improving or Not Not Rocket Science PCOMS simply identifies clients who are not responding so that the lack of progress can be addressed in a proactive way that keeps clients engaged while helpers collaboratively seek new directions but does it improve outcomes? Becoming Better Anker, Duncan,, & Sparks (2009) 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 v TAU; Both persons reliable or sig. change 50.5% 5% v. 22.6%; ES:.50; 4 xs # of clin. sig. change FU: TAU-34.2% v. 18.4% Feedback sep./divorce rate Reese, Norsworthy, & Rowlands (2009) Reese, Toland, Slone, & Norsworthy, 2010 Reese, R., Norsworthy, L., & Rowlands, S. (2009). Does a continuous feedback model improve psychotherapy outcomes? Psychotherapy,46, Reese, R., Toland, M., Slone, N., & Norsworthy, L. (2010). Effect of client feedback on couple psychotherapy outcomes. Psychotherapy, 47, N=148: Feedback group doubled controls (10.4 vs. 5.1 pts); ES:.48 Like Norway study, clients, regardless of risk status, benefit from continuous feedback 2010 study is replication of Norway Trial 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 betteroutcomesnow.com 3

4 Meta-analysis by Lambert & Shimokawa (2011) of PCOMS (the ORS and SRS) Group, Substance Abuse, & PCOMS Schuman, Slone, Reese, & Duncan, 2014 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, RCT of 263 returning Afghanistan and Iraq Vets and Soldiers about to be Deployed: improved outcomes on the ORS, more reliable and clinically significant change, superior clinician and Commander ratings; and reduced drop outs Schuman, D., Slone, N., Reese, R.J. & Duncan, B. (2014). Efficacy of Client Feedback in Group Psychotherapy with Soldiers Referred for Substance Abuse Treatment. Psychotherapy Research. Cooper, M., Stewart, D., Sparks, J., & Bunting, L. (2013). School-based counseling using systematic feedback: A cohort study evaluating outcomes and predictors of change. Psychotherapy Research, 23, Cooper, Stewart, Sparks, & Bunting, 2013 Cohort study of yr olds; caretaker-228; teacher-249; 11 counselors; 28 schools 2 fold advantage over children not using feedback as measured on the SDQ Regarding Provider Variability Feedback Improves Outcomes Norway: 9 of 10 got better outcomes Feedback raised effectiveness of the lower ones to their more successful colleagues. Provider in low effectiveness group became BEST w/feedback! PCOMS Addresses the Problems Recaptures At Risk Clients Feedback tailors services based on response, provides an early warning system to prevents dropouts & negative outcomes, & solves provider variability feedback improves performance as demonstrated in 5 RCTs But What About the Real World? Benchmarking Studies Compares results of RCTs to outcomes in real world. Real world much hharder to secure good outcomes Comparable results would suggest a viable method of quality improvement betteroutcomesnow.com 4

5 Southwest Behavioral Health Public Behavioral Health SBHS, Multicultural PBH Center With a $70 Million Budget Reese, R. J., Duncan, B. L., Bohanske, R. T., Owen, J. J., & Minami, T. (2014). Benchmarking outcomes in a public behavioral health setting: Feedback as a quality improvement strategy. Journal of Consulting and Clinical Psychology, 82, Achieved outcomes comparable to RCTs of depression and feedback. N of 5186; 957 with substance abuse How? PCOMS! Delivers 5 RCTs, the largest benchmarking study ever conducted in public behavioral health, & a cohort study have shown that PCOMS Sdelivers with youth & adults, in individual, couple, & group therapy, with both mental health & substance abuse problems, & with the impoverished and disenfranchised. PCOMS Incorporates the Predictors Early Change and the Alliance Client s rating of the alliance the best predictor of engagement and outcome. Client s subjective experience of change early in the process the best predictor of success for any particular pairing. Some clients do take longer, but the mythology never dies N=4676; 77% attended 8 or less, and 91% 12 or less Note that even for the clients who take longer, change starts early just is flatter Baldwin, S., Berkeljon, A., Atkins, D., Olsen, J., & Nielsen, S. (2009). Rates of change in naturalistic psychotherapy. Journal of Consulting and Clinical Psychology, 77(2), Conclusions: Early change is an important factor for the prediction of short- and long-term outcome. The Research about Early Change Is a Gift Clients who report little or no progress early on will likely show no improvement over the entire course of service, or will end up on the drop-out list early change predicts engagement and a good outcome at termination. Provides a tangible way for us to identify folks who are not responding so that we can chart a new course. Sudden Epiphany? NOT Myth: Clients flat-line & then spike. Some clients do take longer but change starts right away. So the question remains: When do you start getting worried when clients are not responding? I vote for sooner rather than later. betteroutcomesnow.com 5

6 Starting With the Predictors Change and the Alliance Client s rating of the alliance the best predictor of engagement and outcome. Client s subjective experience of change early in the process the best predictor of success for any particular pairing. The Alliance Bordin s Classic Definition 36-50% The Alliance: Relational Bond Agreement on goals Agreement on tasks Up to Seven Times the Impact of Model/Technique; Accounts for Most of Provider Variance Duncan, B. (2014). On Becoming a Better Therapist, 2 nd ed. Washington, DC: APA The Alliance: Over 1000 Research Findings Quality of the alliance more potent predictor of outcome than orientation, experience, or professional discipline Same across modalities and orientations; client populations The Session Rating Scale Measuring the Alliance Factors Accounting for Successful Outcome Give at the end of session; Each line 10 cm in length; Reliable, valid, feasible Score in cm to the nearest mm; Discuss with client anytime total score falls below % 0% Alliance 40.0% Client/Life 15.0% 15.0% Hope/Expectancy Models/Techniques Lambert, M. J. (2013). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield s handbook of psychotherapy and behavior change (6th ed., pp ). Hoboken, NJ: Wiley. betteroutcomesnow.com 6

7 Client/Life Factors Bottom Line Clients Are the Lions of Change Account for Majority of Outcome The quality of the participation [emerges] as the most important determinant of outcome." Engage clients & rally their resources to the cause. Until lions have their historians, tales of hunting will always glorify the hunter. African Proverb Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of process -outcome research: In M. J. Lambert (Ed.), Bergin and Garfield s handbook of psychotherapy and behavior change (5th ed., pp ). New York: Wiley. Clients The Heart of Change Client outcome feedback makes consumers the historians i of their own change Partnering w/clients to monitor outcome engages the most potent factor of change The Alliance The Soul of Change Alliance feedback enables a fit between client expectations, preferences, and services Does not leave the alliance to chance applying over 1000 studies showing the relationship of the alliance to positive outcomes Client Feedback Engages Consumers in a Partnership Overlaps with & affects all factors tie that binds Soliciting feedback is a living, process that engages clients in monitoring outcome, heightens hope, fits client preferences, maximizes therapist-client fit, and is itself a core feature of change. So What Does All This Mean in Terms of Policy? What Can the Data Do for Us? Barry, betteroutcomesnow.com 7

8 The ORS: Reliable and Clinically Significant Change Reliable Change: : Exceeds maturation, chance, and measurement error: 6 on the ORS; Clinically Significant Change: : A change of 6 plus crossing the clinical cut off of 25, a score typical of those not in service Using Data At the Individual Level Becoming Better Linking Outcome to Process See clients more frequently when the slope of change is steep. Begin to space the visits as the rate of change lessens. See clients as long as there is meaningful change. Love Your Data Key Progress Indicators 1. Average Change: Is it above 6? 2. % reaching ETR RCSC 3. Effect Size betteroutcomesnow.com 8

9 Stepping Up Return on Investment People are afraid the data will be used against them often called P4P or pay for performance (punish for performance Better to encourage participation in data management as a continuous quality improvement strategy Arbitrary Performance Standards Will Bring Out the Dark Side Client welfare invoked as an explanation But even the best don t benefit up to a third of their clients. Will promote cheating and ruin the benefits Instead encourage to identify non-responding clients and develop programming to address needs Raise the Bar of Effectiveness and Efficiency Client feedback improves both effectiveness and efficiency engages clients Data collection demonstrates both POV/ROI and serves as a CQI strategy Reward for participation, QI, and creative programming to address non-responders betteroutcomesnow.com 9