Becoming a Better Therapist Partners for Change Outcome Management System Barry Duncan, Psy.D. heartandsoulofchange.com 561.239.3640 barrylduncan@comcast.net barrylduncan@comcast.net 1
Winter Getaway! Training of Trainers Training of Trainers Conference: February 2-6, 2015 (27 CEUs) This intensive training experience gives you all you need to train others and implement PCOMS. And it provides the first step in becoming a PCOMS Certified Trainer. Consumer Driven Outcomes Management Long Ago in a Galaxy Far Away Before the validation studies demonstrated the psychometrics Before RCTs demonstrated the power of feedback to improve outcomes Before the science There was the desire to give consumers a voice in their own care, to bring them into the inner circle that s what started PCOMS barrylduncan@comcast.net 2
Getting Started with PCOMS Just the Facts Ma am Feedback is the way to transcend average. First Things First Why You Might Be Reluctant Finding out is risky What if you find out that you are not so good? What if you are in the wrong profession? The only way we improve is thru feedback. It takes courage. But so does walking in a room with someone in distress. barrylduncan@comcast.net 3
First Things First Why You Might Be Reluctant You might be thinking that you need more paperwork like a hole in the head. Therapists can get really worked up over anything that adds paperwork, especially when they don t see it as clinically useful. And It s Feasible for Everyday Practice Only takes 5 minutes per session! Is clinically meaningful barrylduncan@comcast.net 4
Remember the Predictors? Early Change 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. 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. barrylduncan@comcast.net 5
The ORS Is Not This The ORS Is Different Than Other Outcome Measures 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 barrylduncan@comcast.net 6
Skill Building Becoming Outcome Informed 3 Skills of Outcome Informed Practice (The Three I s) Introducing the Measures Integrating Client Feedback into Practice Informing and Tailoring Services Based on Client Feedback The Outcome Rating Scale An Introduction in Your Own Words The ORS is an outcome measure that allows us to track where you re at, how you re doing, how things are changing or if they are not. It allows us to determine whether the counseling is being helpful so we can do something different if it s not helping. It also is way to make sure that your perspective stays central here, that we are addressing what you think is most important. It only takes a minute to fill out and most clients find it to be very helpful. Would you like to give it a try? barrylduncan@comcast.net 7
O utcom e Score 40 35 30 25 20 15 10 5 0 The First Meeting The Clinical Cutoff 1st 2nd 3rd 4th Session Number Actual Score Line 2 25th % 75th % The dividing line between a clinical & non-clinical population (25). For children (32); adols (28); caretakers (28) Between 20-30% score in the nonclinical range. The Clinical Cutoff Only 2 Choices Either above or below. Mention client score as it relates to the cutoff & have the client make sense of it. Scores under cutoff may seem more straightforward Reporting distress similar to others seeking services the lower the score, the higher the distress. barrylduncan@comcast.net 8
Initial Information In the Clinical Range 40 ORS scor e 30 20 10 0 1 2 3 4 5 6 7 8 9 10 Session number Projected change 75th percentile ORS Scores Estimated Clinical Cutoff 25th percentile Scoring more like people in therapy and wanting something to change ORS: An Example 7.6 5.7 8.0 7.5 What can we glean clinically from this client s scores in addition to being above the clinical cut off? How could we use this information to begin or focus the session? Total = 28.8 barrylduncan@comcast.net 9
The First Meeting Over the Clinical Cutoff Explore why the client entered therapy; circumscribed problem or mandated/coerced If mandated, ask for the referral s rating as a catalyst for conversation; doesn t mean they are lying Avoid stirring the cauldron First Session: Connect ORS to the Client s Described Experience At some point, connect the client s reasons for service to the marks on the scales barrylduncan@comcast.net 10
The ORS The Bare Bones No specific content other than domains a skeleton to which clients add the flesh & blood of their experiences. At the moment clients connect the marks with what they find distressing, the ORS becomes a meaningful measure of their progress and potent clinical tool. Integrating the Measures Has to Be Done Or Becomes an Emotional Thermometer of Day to Day Life And Then Is Worthless barrylduncan@comcast.net 11
Getting a Good Score Two Reasons for Bad Scores Client Doesn t Understand the ORS Client is Angry and Blows It Off Remember the Alliance? 40 Years of Data say 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 12
The Session Rating Scale Measuring the Alliance 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 36 Becoming Better Building the Alliance with the SRS How not to do the SRS barrylduncan@comcast.net 13
Make My Day barrylduncan@comcast.net 14
The Session Rating Scale An Introduction in Your Own Words Let s take a minute and have you fill out the other form that asks your opinion about our work together. It s kind of like taking the temperature of how it went today. Are we too hot or too cold? Do I need to adjust the thermostat? This information helps me stay on track. The ultimate purpose of using these forms is to make every possible effort to make our work together beneficial. If something is amiss, you would be doing me the best favor if you let me know. Can you help me out? Takes Work for Candor But Don t Stress It s All Good Keep encouraging Have to KNOW: No bad news. Not a measure of competence or anything negative about you or the client. Gift from the client that helps you to be better. Unless you really want it, you are unlikely to get it. You won t get it from everyone. barrylduncan@comcast.net 15
The Session Rating Scale A Quick Visual Check Scores < 36 or 9cms should be discussed. SRS is good or its not. Either thank the client for the feedback, & invite them to share future concerns; or thank client & explore why their ratings are lower so that you can fix the concern. Building the Alliance The SRS Graceful Acceptance And a willingness to be flexible usually turn things around. Clients reporting alliance problems more likely for success. Lower scores on the SRS should be celebrated. If clients are comfortable enough to express something isn t right, then you are doing something great. barrylduncan@comcast.net 16
X X X X Now we re ready to be better therapists, but first we must heed the words of a noted psychotherapy scholar Sage Psychotherapy Scholar: Mae West? When I m good, I m very good, but when I m bad, I m better. Granted, at first blush, these hardly seem like words for us to live by but, as it turns out, they are. barrylduncan@comcast.net 17
Becoming Better Identifying Clients Not Responding When outcome is bad in other words, you can make it better by changing something about the therapy to turns things around; and if things don t turn around, by moving the client on to a different provider or service Becoming Better Two Choices Either the client is improving or not. If not, the client is at risk. Engage client in discussion about progress, and what should be done differently if there isn t any. Keeps clients engaged so that a new direction can be planned. barrylduncan@comcast.net 18
Becoming Better When I m Good, I m Very Good When ORS scores increase, when you re good, a crucial step to be very good is help clients see gains as a consequence of their own efforts and make sense of its meaning so repeat in the future. 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 & they desire to continue. barrylduncan@comcast.net 19
Becoming Better Doesn t Mean All Therapy Should Be Brief Au contraire, research suggests that more is better than less for clients who progress early & want to continue. When little or change, however, same data indicates that therapy should, indeed, be as brief as possible. Becoming Better And When Things Are Not Improving Involve the client in the decision about what to do next, to elicit ideas & formulate a plan. Repeated in all meetings, but later ones gain significance and warrant additional action: Checkpoint and Last Chance Discussions. barrylduncan@comcast.net 20
Becoming Better When to Say When Stimulates both client & therapist to struggle with continuing a process yielding little or no benefit. To support what is working & challenge what is not. Urgency increases over time Checkpoint Session: An Opportunity to Be Better Be transparent comment about the lack of progress and seek feedback from the client about what he/she thinks it means 122 barrylduncan@comcast.net 21
When I m Bad I m Better First, the Alliance It doesn t look like we are getting anywhere. Let s go over the SRS to make sure you are getting exactly what you are looking for. Going thru SRS and eliciting client responses in detail can help you & the client get a better sense of what may not be working. Looking at SRS pattern may be instructive When I m Bad I m Better The Last Chance Discussion Driving into desert running on empty, last chance for gas. Depicts the necessity of stopping and discussing the implications of continuing w/o change. barrylduncan@comcast.net 22
Becoming Better Never the LAST CHANCE Doesn t mean the last chance for your client but rather the last chance of a change plan or pairing. No last chance for your client referral can make the difference! Last Chance Longer w/o Change, the Quicker to #6 1. What does the client say? 2. Is the client engaged? 3. What have you done differently so far? 4. What can be done differently now? 5. What other resources can be rallied? 6. Time to fail successfully? barrylduncan@comcast.net 23
Becoming Better Helping Every Single Client All clients can t benefit. Still a way to be helpful. Might have felt like a failure. But when I m bad, I m better. Now successful when client achieves change & when, in the absence of change, I get out of the way. When I m Bad, I m Better Failing Successfully Repeat commitment to help them achieve goals. Failure says nothing about them or their potential. If client wants, meet until arrangements are made. But rarely continue with clients who show no improvement. barrylduncan@comcast.net 24
Failing Successfully Change of Therapist Watershed Client Failing Successfully Awakened me to the pitfalls; taught me to fail successfully. Avoid chronic client the iatrongenic effects of continuing w/o benefit. ORS allows us to ask ourselves hard questions. I wish my helper had failed successfully barrylduncan@comcast.net 25
What People Forget Not Just Flicking a Form A Clinical Process Fully Integrated into the Work Itself Like Everything Else, Success Is up the Therapist: Have to Believe in It, Use It Sincerely, and Make It Their Own Worthless Unless Data Used to Identify at Risk Clients and then Do Something about Them Being Bad Can Make You Better Helps clients you are already effective with by empowering change helps those not benefiting by enabling other options and, in absence of change, the ability to move the client on. When we re good, we re very good, but when we re bad, we can be even better. barrylduncan@comcast.net 26