A Direction from COMPASS. Creating a context for change
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1 A Direction from COMPASS Creating a context for change
2 COMPASS and Outcomes Howard, et al. (1996) Managing as opposed to measuring The clinical success A commercial failure
3 The Working Alliance as Performance Feedback (Comerford, 2003) Working Alliance Inventory Horvath & Greenberg, 1989 Performance feedback Substance Abuse Relapse Reduction System (SARRS)(Now CD) Psybermetrics, 2002 (Now Polaris Health Systems)
4 Table 7 Changes in total pre-feedback (T1 & T2) versus total post-feedback (T3 & T4) in SARRS psychiatric scores Treatment Period Intake mean (sd) Update mean (sd) Wilcoxon signedrank Effect Size Change Score Pre-feedback (T1 & T2) (n=60) 0.23 (0.20) 0.16 (0.17) z=-3.66, p < (0.14) Post-feedback (T3 & T4) (n=66) 0.27 (0.24) 0.14 (0.16) z=-4.98, p < (0.18) Total Sample (n=126) 0.25 (0.22) 0.15 (0.17) z=-6.17, p < (0.16) Mann-Whitney U z=-1.02, ns z=-0.06, ns z=-1.76, z=-1.76, p <.05 p <.05 Between Group 0.36 Effect size
5 Completed Treatment 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Through 2005
6 Client Directed Outcome Informed Miller & Duncan, 2004
7 Psychotherapy Outcomes Client factors (40%) Therapeutic relationship (30%) Techniques (15%) Placebo effect (15%) Client Theory of Change Lambert (1992) Miller & Duncan (2004)
8 Client Directed Unless you develop a working alliance, nothing you do will work. Only what the client believes counts; the client s theory of change. If the client doesn t think it will work it probably won t. The client is the best judge of whether or not your doing a good job.
9 Outcome Informed Only the client knows if it s working. You don t know if it s working if you don t ask. If it s not working more of the same won t work. A higher level of care is not always the answer.
10 You haven't a clue what I m talking about, do you?"
11 Two Instruments The Outcome Rating Scale (ORS) Session Rating Scale (SRS) Miller, Duncan, 2004
12 ORS How have you been feeling? Individually (Personal well-being) Interpersonally (Family, close relationships) Socially (Work, School & Friends) Overall (General sense of well-being)
13 SRS How am I doing? Relationship (Bond) Goals and topics (Goals) Approach or method (Task) Overall
14 Completed Treatment 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% January - December 2006
15 Organizational Influences Navigating the Labyrinth
16 Context Drugs delivered in similar doses to comparable patients produced significantly different results attributable to the facilities where they were delivered. Feighner, Aden, Fabre, Rickels & Smith (1983) Rickes, Fisher, Park, Lipman & Mock (1966) Greenblatt, Grosser & Wechsler (1964)
17 Staff Training and Selection Personal qualities appear to be the factor that make some therapists more helpful than others. Luborsky, McLellan, Woody, O Brien & Auerback (1985) Orlinsky & Howard (1980) There is no significant difference in effectiveness between professionals and paraprofessionals. Christensen & Jacobson (1994)
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19 Rethinking Systems Outcome Building Effectiveness Outcome Support Efficiency
20 The Basic Questions How do we: Eliminate non-essential activities, Make support functions more efficient, and Increase activities that drive outcomes?
21 Payers are asking What do we need to know? What do our requirements cost? What are we really buying? Can we Purchase Outcomes instead of services
22 Every Patient carries her or his own doctor inside. Albert Schweitzer ( )
23 Resources Duncan, B. L., Miller, S. D., & Sparks, J. A. (2004). The heroic client: A revolutionary way to improve effectiveness through client-directed, outcome informed therapy. New York: Jossey- Bass. Hubble, M. A., Ducan, B.L., & Miller, S.D. (1999). The heart & soul of change: What works in therapy. Washington, DC: American Psychological Association.
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