Transcript Slide 1

PREVENTION OF TREATMENT
FAILURE: THE IMPORTANCE OF
PROGRESS FEEDBACK & THE
THERAPEUTIC ALLIANCE MIDST
ALL THE CURRENT EMPHASIS
ON TREATMENT GUIDELINES
michael J. Lambert, Ph.D.
[email protected]
Brigham Young University
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The Problem

10-14% of SMI adults and 14 to 25% of
child clients deteriorate in psychotherapy
 What
shall we do about it????
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Identifying Cases for Review
Little or No
Need (50%)
Moderate
Need (43%)
Great
Need (7%)
Major Issues
1.
2.
3.
4.
5.
Development of change sensitive brief
measures.
Development of expected treatment
response and method of predicting
treatment failure.
Automated method of providing
instantaneous feedback to clinicians and
patients.
Development of Problem-solving tools for
failing cases
Clinical trails to test effects
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Outcome Is:
 Symptom

Distress—internal pain
e.g., I feel hopeless about the future
 Interpersonal


Problems
e. g., I feel lonely
Social Role Functioning

e.g., I feel angry enough at work to do
something I may regret
 Well
being
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Substance Abuse Items
 After
heavy drinking I need a drink the
next morning to get going.
I
feel annoyed by people who criticize my
drinking or drug use.
I
have trouble at work/school because of
drinking/drug use.
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Substance Abuse Items
(continued)
 How
many days in the PAST WEEK did
you drink any alcohol(beer, wine, or
liquor)? 0, 1, 2-3, 4-5, 6-7
 How
many days in the PAST WEEK did
you use any drugs (Marijuana, cocaine,
heroin, speed, others)? 0, 1, 2-3, 4-5, 6-7)
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Measured With
 45-item
self-report (parent-report) scale
taken prior to each treatment session And
delivered to clinician in real time—within 2
seconds.
 The test provides a mental health “Vital
Sign” or “Lab Test” that calibrates current
functioning in relation to functioning prior
to treatment AND expected treatment
response of similar clients WITH ALERTS.
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ALERTS are Essential Because
Clinicians are Overly Optimistic
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Intervals For Group 25
120
110
RED--upper 80% tolerance interval
YELLOW--upper 68% tolerance interval
OQ Total
100
Estimated Line
for group 25
90
GREEN--Betw een upper and
low er 68% toleranceintervals
Red
Yellow
80
Estimate
WHITE--low er 68% tolerance interval
White
Blue
70
BLUE--low er 80% tolerance interval
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Session
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How Well do Practitioners Predict
Treatment Failure?
 Final
Outcome was predicted for 550
Clients
 3 were predicted to have a negative
outcome
 40 had a negative outcome
 Staff identified only one case
 Algorithms predicted 85% of those who
had a negative outcome but false alarm
signals were given at a 2:1 ratio.
Hatfield (2010)
Examined case notes of patients who
deteriorated to see if therapists noted
worsening at the session it occurred.
 If the patient got 14 points worse was
there any recognition? 21%
 If the patient got 30 points worse was
there recognition? 32%

PDA Administration
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Clinician Report
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Assessment for Signal Cases
 My
therapist seems glad to see me
 At times the tone of my therapist’s voice
seems critical
 I could count on friendships when
something went wrong
 I had thoughts of quitting therapy
Alliance Interventions
• Pay careful attention to the amount of agreement between
you and your client concerning overall goals and the tasks
necessary to achieve those goals
• Work with resistance be retreating when necessary and being
supportive
• Provide a therapeutic rationale for your techniques, actions
and behaviors
• Discuss the here and now therapeutic relationship– do not
explain or defend yourself
• Spend more time exploring client feelings
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Research Program

SIX CLINICAL TRIALS IN WHICH WE ATTEMPTED TO REDUCE
DETERIORATION RATES BY PROVIDING PROGRESS
FEEDBACK TO PSYCHOTHERAPISTS
Lambert, et al. 2001
Lambert, et al. 2002
Whipple, et al. 2003
Hawkins, et al. 2005
Harmon, et al. 2007
Slade, et al.
2008
Crits Christoph et al 2011
Simon, et al. Inpatient Eating Disorders, 2012

Random assignment of patients to experimental condition blocked
on therapist (every therapist had patients for whom they received
feedback and were denied feedback) N = 4,000
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90
OQ Total Score
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OT_Fb III
OT-NFb III
NOT-NFb I & II
NOT-Fb I & II
NOT-Fb+CST III
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55
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Pre-test
Feedback
Post-test
Results (Outcome)
Recovered or
Improved
No Change
Deteriorated
NOT-NFb
(n = 286)
60 (21%)
165 (58%)
61 (21%)
NOT-Fb
(n = 298)
104 (35%)
154 (52%)
40 (13%)
NOT-Fb+CST
(n = 239)
121 (51%)
102 (43%)
16 (6%)
Substance Abuse Outcomes
Crits-Christoph, et al 2011 (Journal of Substance Abuse
Treatment)
 Multi-site
study—New York, Philadelphia,
Salt Lake City
 304 patients assigned to feedback or no
feedback within therapists
 Followed across 12 treatment sessions.
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BECOMING AN EMPIRICALLYVALIDATED
PSYCHOTHERAPIST: The value
of applying patient- focused
research in psychotherapy
practice
Variability of Client Outcome as a
Function of the Therapist and What To
Do About It.
 Therapist
 The
Effects Can be Dramatic
individual therapist plays a key role in
outcome and this role is independent of
school-based offerings.
Provider Profile
 Providers
can profile real time change
metrics for themselves—percent of cases
recovered, improved, no change &
deteriorated—to determine strengths &
areas for improvement
 Providers
can view aggregate cases by
diagnosis, gender, etc. for differential
effectiveness in case load
 Providers
contrast differential effectiveness
(e.g., diagnosis) with peers
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Therapist Variability in Outcome

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Since 1996, 270 different professionals and trainees
have provided treatment.
The CCC’s database includes nearly 27,009 individual,
couple, family, biofeedback, and group sessions.
179,000 OQ-45s have been gathered since 1996.
average improvement scores for the 26 current
professionals, compared with an average improvement
score computed for all previous professional therapists
and all past and present trainees.
minimum of 186 clients per therapist to a maximum
of 1,054 clients per therapist;
 On
average, every therapist’s clients
improved.
 The
average of improvement scores
for all past professionals and all
trainees is depicted in black.
 Average improvement scores for 7
therapists (in blue), are significantly
better than this overall average.

4 therapists (in red), had scores significantly
worse than this overall average.

15 therapists (in green), had scores within
this average range.

Therapist 1's average improvement score is
particularly interesting, as it is significantly
better than 24 of the 25 other average
improvement scores.
Nielsen & Okiishi, 2010
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OQ Total Score
70
60
50
Whole Center
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Therapist #1
30
Therapist#56
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10
0
0
1
2
3
4
5
Session #
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7
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In sum…

Ongoing monitoring & feedback:

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Increases overall outcomes
Reduces treatment failures
Improves outcomes for substance abuse
clients
Increases service access by reallocation of
staff time
Identifies best practice groups/clinicians and
those in need of peer-supervision
Saves support staff time when using a fully
automated system.
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