Transcript CLIENT-DIRECTED, OUTCOME

CLIENT-DIRECTED,
OUTCOME-INFORMED
TREATMENT
Randy Walton, Ph.D.
Licensed Clinical Psychologist/Lead Clinician
Colonial Behavioral Health
www.colonialbh.org
www.randywaltonphd.com
Elements of Client-Directed,
Outcome-Informed Treatment
(CDOI)
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Treatment effectiveness is based upon client
goals and perceptions
Partnership between therapist and client
Regular, ongoing client feedback
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Effectiveness
“Fit” between client and therapist
Treatment adjusted based upon client feedback
QUIZ
Q: Is psychotherapy effective?
A: Yes
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40-70% of clients who
receive psychotherapy
receive substantial benefit

The average treated person
is better off than 80% of
the untreated sample in
most studies (i.e., the
“effect size” of therapy is
about 80%, similar to
effect size for coronary
artery bypass surgery)
Effectiveness of Psychotherapy
Bottom line:
The majority of psychotherapists are
effective and efficient most of the
time.
Effectiveness of Psychotherapy
 Additional
good news:
•
Research shows that only 1 out of 10 clients
on the average clinician’s caseload is not
making any progress.
•
Average treated client accounts for only 7%
of expenditures.
So why CDOI?
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However, research demonstrates particular areas in
which therapists can improve
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Dropout rates average about 50% (U.S., Canada, U.K.)
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About 10% of clients do not improve, or deteriorate, while in
treatment
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Therapists frequently fail to identify failing cases
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1 out of 10 clients accounts for 60-70% of expenditures (staff
time, resources)
So why CDOI?
Improvements in these areas can be
accomplished with two very simple CDOI
activities:
1.
Measuring and discussing the impact that our
work is having on our clients from session to
session (i.e., effectiveness)
2.
Obtaining and discussing session to session
feedback about the status of our relationship with
our clients (i.e., therapist-client “fit”)
Effects of CDOI Tools
When therapists measure and discuss their
work with their clients on an ongoing basis:
 The
clients have better outcomes
 The
clients have stronger therapeutic alliances
CDOI Tools
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Outcome Rating Scale (ORS) :
Measures outcomes/results (i.e.,
effectiveness) of services

Session Rating Scale (SRS) :
Provides feedback regarding the status
of the therapist-client relationship
Effects of CDOI Tools
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When the ORS and SRS are used each session
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Clients are empowered and their voice is privileged
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Clients are more engaged in therapy as a mutual endeavor
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Clients can identify times when there is a problem in either:
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progress (ORS)
status/fit of the relationship (SRS)
Treatment is informed and guided by client feedback (think
“therapeutic GPS”)
Effects of CDOI Tools
What the research shows:
When therapists measure the status of the alliance and the
status of progress on an ongoing basis, and most
importantly discuss that information with their clients
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Outcomes can be improved by up to 65%
The number of clients who drop out of treatment has
been reduced by half
Accountability, credibility, and
control
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Over the past 20 years, the push for “accountability” has
become increasingly prominent (payers, administrators,
regulators, clients)
However, therapists have not actively asserted what we
know about effective therapy
Consequently, therapists have lost significant credibility
and control over clinical practice
Instead, payers, regulators, administrators, and business
stakeholders (e.g., pharmaceutical companies) have
dictated clinical “best practices”, including treatment
approaches/models and documentation.
TRUE OR FALSE QUIZ
Q: Of all the factors
affecting treatment
outcome, the
treatment model or
technique is the most
potent.
A: False
Technique makes the
smallest contribution
to psychotherapy
outcome of any
known ingredient.
Conclusions from Meta-analytic
Studies
Common Factors associated with
Psychotherapy Outcome
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“Extra-therapeutic” Factors (40%)
Therapeutic Alliance (30%)
Therapy Model or Technique (15%)
Placebo Effect (15%)
Hubble, Duncan, Miller 1999. The Heart and Soul of Change: What
Works in Therapy. APA
Conclusions from Meta-analytic
Studies
Common Factors associated with Psychotherapy
Outcome
“Extra-therapeutic” Factors (87%)
 Therapeutic Factors (13%)
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Therapeutic Alliance (8%)
 Therapeutic Allegiance (4%)
 Therapy model or technique (1%)
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Wampold, B.E. 2001. The Great Psychotherapy Debate: Models, Methods,
and Findings. Erlbaum.
Conclusions from Meta-analytic
Studies
Psychotherapy models or techniques account for a small
amount of the variance in psychotherapy outcomes
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Virtually all psychotherapy models and techniques are
effective with some people, some of the time
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Differences in outcome between models is consistently
small or negligible
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Outcome differences between therapists using the same
model have been found to be 2-3 times greater than the
differences between models
So Why CDOI?

In spite of the data:
 Many
therapists firmly believe that the
expertness of their techniques leads to
successful outcomes
 The
field as a whole is continuing to embrace
the medical model.
 Emphasis
on so-called, “empirically supported
treatments” or “evidence based treatments.”
 Embracing the notion that accurate diagnosis leads
to effective treatment
Therapeutic Relationship/Alliance
and Therapy Model/Technique
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Research shows that the therapeutic model or
technique used by a therapist is primarily
effective not when paired with a specific
diagnosis, but when it matches the client’s
“theory of change”:
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The client’s:
 View of the problem
 View of the change process
 Goals and expectations
 Desired pace for treatment
CDOI: The Client is Central
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The capacity for self understanding,
problem-solving, and growth, resides
primarily in the client
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The most effective therapists are ones
who allow or help their clients to develop
their own understanding and solutions to
problems
QUIZ
Q: Who is better at
identifying whether a
client is making progress
in psychotherapy, the
therapist or the client?
A:THE CLIENT
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Research shows that
therapists are remarkably
bad at judging whether a
client is making progress in
psychotherapy.
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The client’s experience of
meaningful change ,
especially early in therapy
(first 4-5 sessions) is one of
the best predictors of a
positive therapy outcome.
QUIZ
Q: Who is better at
accurately rating
the quality of the
therapeutic
relationship and
therapeutic alliance,
the therapist or the
client?
A: THE CLIENT
Research shows
that the client’s
rating is clearly
superior to the
therapist’s in
predicting
psychotherapy
dropouts.
CDOI: Synthesizing client centrality
and evidence-based practices
“Evidence-based
practice in psychology (EBPP) is the integration of the best
available research with clinical expertise in the context of patient characteristics,
culture, and preferences.” [italics added]
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“Clinical expertise is used to integrate the best research evidence with
clinical data (e.g., information about the patient obtained over the course of
treatment) in the context of the patient’s characteristics and preferences to
deliver services that have a high probability of achieving the goals of
treatment.”
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“Psychologists’ clinical expertise encompasses a number of competencies
that promote positive therapeutic outcomes. These competencies include
…making clinical decisions, implementing treatments, and monitoring
patient progress … possessing and using interpersonal expertise, including
the formation of therapeutic alliances” [italics added]
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“Ongoing monitoring of patient progress and adjustment of treatment as
needed are essential to EBPP.”
American Psychological Association Statement: Policy Statement on Evidence-Based Practice in Psychology (August,
2005)
So why CDOI?
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Psychotherapeutic processes, models, and techniques
are best informed and directed by systematic and
ongoing assessment of the “fit” and the “effect” of any
given therapeutic relationship.
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Therapeutic processes, models, and techniques are not
well informed and directed by:
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Static concepts such as diagnosis
Unreliable or inaccurate theories and impressions of the
therapist
Rigid adherence to a model regardless of fit and effect
CDOI Tools
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Use of rating scales for ongoing feedback
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Outcome Rating Scale (ORS)
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Session Rating Scale (SRS)
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Measures “Effect”
Four rating scale items, about one minute to administer and score
Administered, scored, and graphed at beginning of every session
Discuss and use improvement, decline, or no change
Measures “Fit”
Four rating scale items, about one minute to administer and score
Administered, scored, and graphed at end of every session
Discuss any low scores
These scales, along with the administration and scoring manual, are
available for free download and printing:
http://heartandsoulofchange.com/measures/
Outcome Rating Scale (ORS)
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)
I----------------------------------------------------------------------I
Interpersonally
(Family, close relationships)
I----------------------------------------------------------------------I
Socially
(Work, school, friendships)
I----------------------------------------------------------------------I
Overall
(General sense of well-being)
I----------------------------------------------------------------------I
Institute for the Study of Therapeutic Change
_______________________________________
http://heartandsoulofchange.com/measures/
© 2000, Scott D. Miller and Barry L. Duncan
Session Rating Scale (SRS V.3.0)
Please rate today’s session by placing a mark on the line nearest to the descriptions that best fits your
experience.
I did not feel
heard,
understood, and
respected.
Relationship
I----------------------------------------------------------I
I felt heard,
understood, and
respected.
We did not work
on or talk about
what I wanted
to work on or
talk about.
Goals and Topics
I----------------------------------------------------------I
We worked on
and talked 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.
Approach or Method
I----------------------------------------------------------I
Overall
I----------------------------------------------------------I
Institute for the Study of Therapeutic Change
http://heartandsoulofchange.com/measures/
© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnsaon
The therapist’s
approach is a
good fit for me.
Overall, today’s
session was
right for me.
Graphic Representation of ORS and SRS Results
ASIST for Agencies 3.51, David Elliott. Available for purchase at
http://www.clientvoiceinnovations.com/A4A
CDOI Tools: ORS and outcomes
Here is what we know from the research:
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Clients who begin to experience positive change early
in treatment are very likely to end treatment on a
positive basis
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Clients who are not successful in the early stages of
treatment are very likely to drop out of treatment,
or…
not drop out of treatment, and stay in a treatment
that does not change, and does not change them
CDOI Tools: SRS and Therapeutic
Relationship/Alliance
Here is what we know from the research about the
therapeutic relationship/alliance:
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It is the single most important therapeutic factor in
a positive psychotherapy outcome
Dynamic not static: relationship and alliance change
over time
More predictive of psychotherapy outcome than
diagnosis
More predictive of psychotherapy outcome than
model or technique
Predictive of client dropout
Value of CDOI
To summarize:
When the ORS and SRS are (1) administered
to clients on an ongoing basis, and (2) the
client and therapist work together to talk
about them, outcomes improve by as much
as 65% and dropout rates decrease by about
half.
Value of CDOI
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CDOI provides:
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a simple means of improving the value of our clinical work to our
clients
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a simple means of improving clinicians' effectiveness
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a simple means of improving and demonstrating the value of
our clinical work to payers of therapy services
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A simple means of increasing therapists’ autonomy,
accountability, and credibility
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A simple means of potentially and significantly reducing
necessary clinical documentation
Value of CDOI
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Right now, “accountability” is monitored, and therapists
and health information professionals are inundated with,
extensive paperwork, oversight, and regulatory
measures
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Clinicians writing that their client is getting better is not likely to
change this
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Client testimonials that our work is great is not likely to change
this
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Hard data/evidence that therapy works and has value is likely to
change this
Value of CDOI
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What payers want:
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Demonstrated return on their investment
Value for their dollar
Accountability
Their stake is in the outcome of the
service for which they are paying
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If payers have data demonstrating outcome,
they have little need for diagnoses, treatment
approach used, or extensive documentation to
review
Value of CDOI
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What stakeholders and regulatory agencies want:
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Demonstrated benefit to the clients
Evidence that clients’ welfare and rights are protected
Their stake is in consumer protection and satisfaction
with services
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The CDOI emphasis on the centrality of the client and
his or her values, preferences, needs, strengths, and
ongoing feedback to guide treatment, embraces
stakeholder values
Value of CDOI
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What clients want:
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A positive outcome (i.e., achieve the changes they want )
Trust, respect, and safety
Value for their time and money
Their stake in therapy includes that of both
payers and stakeholders/regulatory agencies
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Demonstrated improvements in outcomes and
satisfaction using CDOI treatment principles addresses
client wants/needs in a way which they typically find fun,
educational, and validating.
Value of CDOI
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What therapists want:
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Competence
Autonomy
Good reputation with clients and peers
Financial remuneration
Client feedback regarding effectiveness and
therapeutic “fit” allows a therapist to make
adjustments when there is a problem in either
area, openly validate their competence, and
practice more autonomously
Value of CDOI
Using CDOI principles and tools is a “winning” situation for all parties
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Clients win because they get to see they are working successfully with
their therapist, give feedback if they are not, and receive validation that
their feedback is valued and guides treatment.
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Payers win because they have documented return on their investment

Stakeholders/regulators win because CDOI embraces their values
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Therapists win because they get to maintain their professional autonomy,
what happens in therapy is decided between the therapist and the client,
paperwork is potentially reduced, and they can demonstrate the value of
their service.

Health information professionals win because their job is simpler and
easier when clients, stakeholders, regulators, and therapists are satisfied
more simply and efficiently