The Heart and Soul of Change

Transcription

1 The Heart and Soul of Change Barry Duncan, Psy.D. heartandsoulofchange.com

2 Psychotherapy The Good Study after study, and studies of studies show the average treated client is better off than 80% of the untreated sample. Psychotherapy The Bad Drop out rates average 47% Therapists vary a lot barrylduncan@comcast.net 2

3 Therapist Differences Incredible Variation Among Providers TDCRP: top third psychiatrists giving placebo bested bottom third giving meds; clients of best counselors improve 50% more & dropped out 50% less; meds useful for clients of more effective, not for less--what accounts for the variability? Stay tuned Kim, D., Wampold, B., & Bolt, D. M. (2006). Therapist effects in psychotherapy: A random effects modeling of the NIMH TDCRP data. Psychotherapy Research, 16, More Bad: Public Behavioral Health Hansen, Lambert, and Forman (2002) 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 barrylduncan@comcast.net 3

4 Spurned 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. 4

5 TDCRP The Alliance Considered most sophisticated comparative clinical trial ever: CBT, IPT, Drug, Placebo No difference in outcome The client s rating of the alliance at the second session the best predictor of outcome across conditions. Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, Project MATCH The Alliance CBT, 12-step, & Motivational Interviewing NO difference in outcome The client s rating of the alliance the best predictor of: Treatment participation; Drinking behavior during treatment; Drinking at 12-month FU Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 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. Journal of Consulting and Clinical Psychology, 65(4), barrylduncan@comcast.net 5

6 The Dodo Also Rules Family Therapy Cannabis Youth Treatment Project 600 Adolescents marijuana users: Significant co-morbidity (3-12 problems). Two arms (dose, type) and one of three types of treatment in each arm: Dose arm: MET+CBT (5 wks), MET+CBT (12 wks), Family Support Network (12 wks)+met+cbt; Type arm: MET/CBT (5 wks), ACRT (12 weeks), MDFT (12 wks). Approach accounted for 0% of the variance in outcome. Ratings of the alliance predicted: Premature drop-out; Substance abuse and dependency symptoms post-treatment, and cannabis use at 3 and 6 month follow-up. What About Evidenced Based Treatments Dodo applies. If they aren t better than other approaches, then what are they better than? Placebo, a less than equal opponent, or no tx not saying much if a friend went out on a date, you asked about the guy, your friend replied, He was unequivocally better than watching TV or washing my hair. How impressed would you be? Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, And the conclusion barrylduncan@comcast.net 6

7 The Search for the Holy Grail Doesn t Do Much for Us Helping is no more effective now with all our treatment technologies (400 of them) and evidence based treatments (over 150 of them) than 40 years ago. 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 barrylduncan@comcast.net 7

8 No More Head in the Sand Despite overall efficacy, dropouts a problem, not everyone benefits, therapists vary significantly, outcomes in many settings are dismal, & the primary QI strategy has problems. And the Ugly Providers Don t Know 20-70% range 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: / 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 barrylduncan@comcast.net 8

9 To The Rescue, Another QI Strategy Continuous Client Feedback Howard et al. (1996) advocated for the systematic eval. of client response during treatment to determine the appropriateness of the current tx the need for further tx [and] prompt a clinical consultation for patients who [were] not progressing at expected rates Feedback and Outcome Lambert s Seven Trials All 7 sig. gains for feedback 22% of TAU at-risk cases improved compared with 33% for feedback to therapists, 39% for feedback to therapists & clients, & 45% when supplemented with support tools A strong case for routine measurement of outcome in everyday clinical practice barrylduncan@comcast.net 9

10 PCOMS Outcome and Alliance Feedback The ORS Download free working copies at: The SRS 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 positive, proactive way that keeps clients engaged while therapists collaboratively seek new directions barrylduncan@comcast.net 10

11 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% 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 barrylduncan@comcast.net 11

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

13 Cooper, Stewart, Sparks, & Bunting, 2012 Benchmark 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 Group, Substance Abuse, & PCOMS Schuman, Slone, Reese, & Duncan, 2014 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. barrylduncan@comcast.net 13

14 Two More in the Works Group and Youth Submitted: Group psychotherapy: improved outcomes and improved retention Completed: RCT of intervention in the schools with children and adolescents with behavioral problems Slone, N., Reese, J., Matthews-Duvall, S. & Kodet, J. (2014). Using feedback to improve group psychotherapy outcomes. Murphy, J., & Duncan, B., Reese, R.J., Bohankse, R., Gillaspy, A., & Zatoga, A. (in process). Using client feedback to improve school intervention outcomes. 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. How? PCOMS barrylduncan@comcast.net 14

15 Becoming Better Recapture Your At Risk Clients Feedback tailors services based on response, provides an early warning system to prevents dropouts & negative outcomes, & solves therapist variability feedback improves performance Regarding Therapist Variability Feedback Improves Outcomes Norway: 9 of 10 got better outcomes Feedback raised effectiveness of the lower ones to their more successful colleagues. Therapist in low effectiveness group became BEST w/feedback! barrylduncan@comcast.net 15

16 Provider Variation Feedback Improves Effectiveness Counselor's Outcomes (n=30 or more cases) Effect size (n=94) 2 (n=74) Mean Effect Size for all Cases 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) Counselor 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) And Finally (and why PCOMS started) Puts the client s voice center stage the only system that is collaborative by design Allows services to be client and family driven Brings clients into the inner circle of decision-making Partners in recovery-driven services barrylduncan@comcast.net 16

17 But What Else Can We Do What Else Accounts for Variability One Possibility One No- Brainer Factors Accounting for Successful Outcome 40.0% Client/Extratherapeutic Relationship 30.0% Models/Techniques 15.0% Placebo/Hope/Expectancy 15.0% Lambert, M. (1986). Implications of Psychotherapy Outcome Research for Eclectic Psychotherapy. In J. Norcross (Ed.) Handbook of Eclectic Psychotherapy. New York: Brunner/Mazel. 17

18 Client/Life Factors (86%) (includes unexplained and error variance) Treatment Effects 14% Feedback Effects 21 42% Alliance Effects 36 50% Model/Technique: Specific Effects (Model Differences) 7% Therapist Effects 36 57% Model/Technique: General Effects (Rational & Ritual), Client Expectancy (Placebo), & Therapist Allegiance 28?% Successful V. Unsuccessful Therapists Focus on Strengths Unsuccessful therapists focused on problems, neglected strengths; problem activation Successful helpers focused on recruiting strengths to address problems; resource activation But is this what we do? Gassman, D. & Grawe, K. (2006). General change mechanisms: The relation between problem activation and resource activation in successful and unsuccessful therapeutic interactions. Clinical Psychology and Psychotherapy, 13,

19 The Killer D s of Client Diminishment Dysfunction Disorder Disability Disease Deficit Damaged Not Reliable or Valid None ever related to outcome need to Get Over it! Diagnosis Our Founding Parent I have found little that is good about human beings. In my experience, most of them are trash. --Sigmund Freud, M.D. barrylduncan@comcast.net 19

20 Clients Are the Lions of Change Account for Majority of Outcome Until lions have their historians, tales of hunting will always glorify the hunter. African Proverb Casting the Client in Heroic Roles No formula here, more of an attitude requiring a balance between listening empathically with mindfulness toward resources that you know are there. Identify not what clients need, but what they already have in their world that can be put to use in reaching their goals barrylduncan@comcast.net 20

21 Finding Ways that Are Authentic Finding 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? What kind of person do these aspects describe? Or, what kind of person do these aspects show an aspiration toward? Finding Ways that Are Authentic Finding the Heroic Client Who was the first person to tell you that they noticed the best of you in action? What were you doing when they noticed these aspects? Who was the last person to tell you that they noticed the best of you in action? Who in your life wouldn t be surprised to see you stand up to these situations and prevail? What experiences would they draw upon to make these conclusions about you? What quintessentially you stories would they tell?...kim barrylduncan@comcast.net 21

22 Kim and the Stories that Came with Her Story of Crack- Addicted Story of Having Her Three Children Removed by CPS Kim s Heroic Stories Story of overcoming adversity. Story of protecting her children from abuse. Story of overcoming crack for 17 months. barrylduncan@comcast.net 22

23 Clients The Heart of Change Client outcome feedback makes consumers the historians of their own change Partnering w/clients to monitor outcome engages most the potent factor of change Therapist Variables that Predict Change Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, 75(6), ; Owen, Duncan, Anker, & Sparks (i2014). Therapist effects in couple therapy. Journal of Family Psychology. Therapists with the best results: Are better at the alliance across clients; alliance ability accounts for most of therapist differences 23

24 The Therapeutic Alliance Bordin s Classic Definition The Alliance: 36-50% Relational Bond Agreement on goals Agreement on tasks Up to Seven Times the Impact of Model/Technique; Accounts for Most of Therapist 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-- recall TDCRP, MATCH, CYT. Same across modalities and orientations; client rarely tell us if it s bad. Is predictive even when early change is controlled barrylduncan@comcast.net 24

25 Empathy, Positive Regard, Genuineness Carl Rogers Was On To Something Empathy: Meta-analysis (MA) of 57 studies found r of.31; Positive Regard: MA of 18 studies found r of.27; Genuineness: Meta-analysis of 16 studies found r of.24 Eachmore powerful than any technique you can ever wield (Lambert, 2013). Model differences a d of.20. Collaboration & Agreement on Tasks Again More Powerful than Technique Agreement on Methods to Achieve Goals: 15 studies, d of.34, better outcomes with agreement; Collaboration:19 studies, d of.33, better outcomes w/cooperative relationships Shick Tryon, G., & Winograd, G. (2011). Goal consensus and collaboration. Psychotherapy, 48, barrylduncan@comcast.net 25

26 But Perpetually Minimized in Difficulty and Importance It gets such little press compared to models and techniques and is often relegated to statements like first gain rapport and then or form a relationship and then as if it is something we effortlessly do before the real intervention starts. The alliance is not the anesthesia to surgery. The alliance deserves far more RESPECT When the alliance is in trouble Consider Lizbeth The Stories Told: Abused Kid Angry Kid Defiant Kid Violent Kid Foul-Mouthed barrylduncan@comcast.net 26

27 Lisbeth and Sophie s Heroic Story Story of a brilliant girl overcoming incredible obstacles; many strengths; crusty old sailor. Story of a girl who wants to set the record straight; Story of an amazing foster mom, one in a million. And a crusty old man, Barry 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 barrylduncan@comcast.net 27

28 Reliance on the Alliance Bottom Line The Alliance is the Best Friend We Have in the Therapy Room PCOMS Starts 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. barrylduncan@comcast.net 28

29 Sooner Rather Than Later Who drops out? A B The bulk of change occurs sooner rather than latter Howard, K. et al. (1986). The dose-effect response in psychotherapy. American Psychologist, 41, It s A Fact Early Change is The Rule Early change in treatment is a robust predictor of outcome and retention in treatment. Gotta measure outcome! Cannabis Youth Treatment Project Project MATCH Babor, T.F., & DelBoca, F.K. (eds.) (2003). Treatment Matching in Alcoholism. United Kingdom: Cambridge, 113. barrylduncan@comcast.net 29

30 The Rule: Treatment of Depression Collaborative Research Program TDCRP Conclusions: Early change is an important factor for the prediction of short- and long-term outcome. Lutz, W., Stulz, N., & Köck, K. (2009). Patterns of early change and their relationship to outcome and follow-up among patients with major depressive disorders. Journal of Affective Disorders 118(1), 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: Contrasting dose-effect and good-enough level models of change. Journal of Consulting and Clinical Psychology, 77(2), barrylduncan@comcast.net 30

31 Becoming Better Measuring Outcome Give at the beginning of the visit; Client places a mark on the line. Each line 10 cm (100 mm) in length. Reliable, valid, feasible Scored to the nearest millimeter. Add the four scales together for the total score. Becoming Better Feedback Is My Compass Not an uninhabited terrain of technical procedures, nor the predictable path of diagnosis, prescription, & cure. Cannot be described w/o the client & therapist, co-adventurers in a journey across uncharted territory. Common factors provide landmarks for this interpersonal & idiosyncratic trip, & specific models provide welltraveled directions to consider, but feedback provides the compass, showing the way to the desired destination. barrylduncan@comcast.net 31

32 Answers the Call Consumer-Centered, Recovery-Based New Freedom Commission: Care is consumer-centered, with providers working in full partnership with the consumers they serve to develop individualized plans of care. SAMHSA and Partners: National Consensus Statement on Mental Health Recovery PCOMSonly system that partners with consumers What Separates The Best? Barry s Recipe 1. Feedback Improves Outcomes More than Anything since 2. The Heart: Clients Account for Most of Change: Rally, Recruit, and Harvest their Resources for Change 3. The Soul: Rely on the Tried & True Old Friend, the Alliance barrylduncan@comcast.net 32