client directed outcome informed services the problem ...tkrieshok/epsy888/cdoi_cliff_notes.pdf ·...

Client Directed Outcome Informed Services The Problem: Outcomes no better now than in the 1960’s Lambert’s work: 2/3 get better with therapy, but 10% get worse (15-25% for kids) Sometimes we cause it, more often life events AND, therapists almost never see that outcome coming (though they could with feedback) Feedback as another common factor? We’re overly optimistic, which is normally a good thing, but it means we need to rely on data to recognize change and deterioration. The most common problem in cases of deterioration is NOT the bond, but disagreement on tasks and goals of therapy. Old: Identify problem. New: Identify resources client brings to work on the problems. Resource activation vs. problem activation. Whatever you attend to becomes central. Heroic stories as opposed to problem stories. Look for STORIES that will Energize. Focus on Strengths, to take advantage of the majority of change variance due to things related to what the CLIENT is doing/bringing/experiencing, that has little or nothing to do with therapy. What works? Common Factors: 1. Alliance (Rogers’ triad) 2. Agreement on goals and tasks The quality of the client’s participation is the most important thing. Alliance is our craft. Rather than the model being the fuel for change, it is the alliance. Attend to folks as if you are on a first date. 1. Be friendly 2. Empathy: GET the client, validate, we have to communicate to clients that we know they transcend their problems. 3. Work with the client’s goals 4. Fit the client’s theory of change. Litmus test: Does it get the client engaged? Client is the heart; Relationship is the soul. Put People in charge of their treatment. When clients become the Subject of the treatment (as opposed to the Object) they attend and engage.

Feedback helps with both Alliance and Agreement on goals and tasks Feedback = early warning system Feedback has an effect size of .50 by itself. Jeff Reese's finding that trainees with feedback improved twice as much as those without. Work the scores into your session. If things were just 1cm better, what would that look like? So this item is the lowest, do you want to talk about that? How long would you need to go doing better before you’d feel comfortable spacing this out? Clients who aren’t doing well with us are the ones who bring out the best in us. Orlinsky and Helge Ronnstad: How Psychotherapists Develop. Your view of yourself is critical to your vitality as a professional. The key is Healing Involvement, and you get there 3 ways: 1. Cumulative career development (track outcomes) 2. Theoretical breadth (theoretical promiscuity brings uncertainty--in a good way) 3. Currently experiencing growth (learning through clinical work) Michael Lambert’s OQ45 His measure has 45 items, tapping into Alliance Social Support Life events Motivation In constructing the instrument, they only picked items that identify problems you can actually address in treatment (e.g., perfectionism is a predictor of poor outcomes, but we can’t really address that in brief treatment). Rather than thinking in terms of what I (the all powerful one) bring to the client and give to the client, focus instead on how my job is to elicit what the client already has, their strengths, their resources in themselves and in their community. CDOI puts us face to face with our shenpa, our uneasiness. Working with the client as the center requires us to move away from Praise and Blame. Who in your life wouldn't be surprised to see you overcome the problem before you now? Who in your life wouldn't be surprised to see you stand up and be successful in this situation; and if they were here in the room right now, what story would they tell about you that would convince me to believe in you in that same way?

What are the hidden strengths the client brings? Resonate with despair, but refuse to succumb to it. What are the alternative stories about the client? We know the story about their problem. What are some additional stories about them and their strengths. Since nobody is just one story. In therapy, embracing uncertainty creates a space where all things heretofore unspoken about the client and their situation can emerge. These are cynical times, so it's a bit hard to have faith that therapy can work, that people can change, and that we can participate in that process. Your clients need for you to have that, and your professional and personal survival depend on your ability to have it as well. Lori Ashcraft Getting better => Symptoms gone Recovery=>Shame and fear gone Power shifts from practitioner to client. Our job is to get the power back into the client, so they can manage their recovery. Stay connected to the person (eye contact), not the problem.

Three Skills of Outcome Informed Practice Adapted from Duncan, B. (2010). Six skills of CDOI. Available at

www.heartandsoulofchange.com. 1. Build a Culture of Feedback

Introducing the O/SRS requires viewing feedback as a gift from the client that can only improve outcomes. Fit the introduction into your own language and style; and score and chart the measures during interactions.

2. Integrate Client Feedback into Practice

Integration requires: 1) Providing feedback about the client’s score and the clinical cutoff and allowing the client to make sense of it; 2) Connecting the client’s described experience to his or her marks on the different scales; and 3) Ensuring that the client’s rating represents the client’s described experience - that you have a good rating on the ORS.

3. Informing and Tailoring Services Based on Client Feedback

1) Compare the current ORS score with the last. If there is change, implement the

“Listening for a Change” skill. If no change, discuss with the client what needs to happen

next. 2) If no change persists, the discussions increase in urgency, represented by a Checkpoint Conversation and/or a Last Chance Discussion, both intended to brainstorm options and entertain the possibility of referring the client elsewhere. 3) If no change persists, it is time to fail successfully, or do a warm handoff to another provider or

program.

Three Skills of Client Directed or Common Factors Practice Adapted from Duncan, B. (2010). Six skills of CDOI. Available at

www.heartandsoulofchange.com.

1. Recruit Client Resources

A. Telling Heroic Stories: Assist the client in telling his or her story of survival and courage that portrays their courage and heroism by using reflective listening and the OARS skills of motivational interviewing.

B. Listening for a Change: Spotlight the client’s resources that may be available for further movement. Help clients notice the link between past behavior changes and their role in making the change(s) happen. Elicit self-change talk.

2. Rely on the Alliance

A. Stay Close to the Client’s Experience: Use the client’s language - their words, ideas, and expressions and carefully monitor her or his reaction to comments, explanations, interpretations, questions, and suggestions. Initially, stay “within an inch” of the client’s descriptions of their lives, and walk softly next to them when taking a different path. Use complex reflective listening to direct the conversation toward goals and tasks.

B. Validate the Client’s Experience: Accept the client at face value and search for justification of his or her experience - replacing other’s invalidation that may be a part of it. Validation occurs when client’s thoughts, feelings, and behaviors are accepted, believed, and considered completely understandable given trying circumstances. Legitimize the client’s concerns and highlight the importance of the client’s struggle.

C. Work on the Client’s Goals: Period! Ask directly about goals and continue to discuss and monitor.

3. Match the Client’s Theory of Change

The client’s theory of change is simply his or her ideas and preferences about how he or she can be best helped. It unfolds from a conversation structured by your curiosity about the client’s ideas, attitudes, and speculations about change. Honoring the client’s theory occurs when you follow, encourage, and implement the client’s ideas for change and assist in selecting a recovery pathway, technique or procedure that fits the client’s beliefs about the problem(s) and the change process.

CLIENTS: THE NEGLECTED COMMON FACTOR IN PSYCHOTHERAPY [Chapter 9 in The Heart and Soul of Change: Delivering what works in therapy, 2009, edited by Duncan, Miller, Wampold, and Hubble] ART BOHART AND KAREN TALLMAN Regarding helpful therapist behaviors, research yet again points in the direction of nonspecific factors. Clients have emphasized being understood, accepted, and actively supported. These findings were corroborated in a study (conducted and published in Psychology Today) of more than 2,200 clients (Harris Interactive, 2004). Using data gathered online and via telephonic survey, researchers found that clients considered listening skills (63%), personality (52%), personal connection (45%), and activity level (38%) as the most essential qualities of a good clinician. Other studies have found that clients' progress in treatment is hindered when therapists (a) make hurtful remarks; (b) are authoritarian; (c) do not listen; (d) remain silent, distant, or unresponsive; (e) refuse to give advice, ideas, or practical exercises; (f) differ significantly from the client in personality; and (g) are distant and untrustworthy (Conrad & Auckenthaler, 2007; Von Below & Werbart, 2007). In all, research about client preferences suggests that clients want a safe space to talk with someone who will listen and appreciate what they think is important. Is that too much to ask? Implications for Training Train therapists to value clients: their strengths, resources, ideas, and propensity for self-healing. Therapists in training should be encouraged to do the following: • Begin with the assumption that clients make therapy work-- that clients are both resilient and reasonable, but stuck in a difficult situation. • Take seriously the client's perspective on the problem and honor that perspective. Encourage clients to understand that there are multiple correct points of view. Certainly no one point of view offered by approaches to psychotherapy can be said to be "the" correct one. • Expect clients will get better, and believe that therapy works and that the person sitting across from them will change. Trainees can gain confidence in knowing this by tracking client progress via outcome measures and making notes of the new skills, ideas, goals, and insights clients mention each week. • Support the clients' efforts so they can leave therapy and be effective problem solvers on their own. Allow clients to originate some of the solutions.

Train therapists to listen; listening is an art. Therapists in training should be taught the following: • Be effective, supportive listeners instead of being diagnosticians or interventionists. Diagnosis encourages an external perspective on the client as well as a view of the client as broken or damaged. The introduction to pathology and diagnosis should be delayed until the therapist gains skills in relating to clients. Instruction in the art of dialogue and the study of communication should be included before the introduction of models and techniques. Put models and techniques in their place-not discounting them, but understanding their relative importance in psychotherapeutic change. Use a collaboration metaphor for therapy rather than the widely accepted adversarial, often combative, metaphor. It is not "us" against "them" or even "us" against the problem or pathology. It is both the therapist and client in partnership against the obstacles the client views in his or her life. • Value the power of listening. Beginning therapists should practice their listening skills in triads, acting as the therapist, the client, and the observer. As conversation unfolds and methods of exploration are tried, trainees learn to evaluate any given position or technique from multiple points of view. Firsthand experience of varied perspectives encourages flexibility and an ongoing appreciation of diversity of views. • Be comfortable with silence. Silence is critical when the client is thinking effectively, engaging in self-reflection, imagining new possibilities, and considering changes. • Include client feedback in their understanding of their listening and relational skills. It is the client's perceptions that make the difference: You are not listening until the client says you are.

Barry Duncan, Psy.D. [email protected] www.talkingcure.com; www.whatsrightwithyou.com

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Research makes clear that the client is actually the most potent contributor to successful

outcome—the resources clients bring into your agency and what influences their lives outside it.

These factors might include persistence, openness, faith,

optimism, a supportive grandmother, or membership in a

religious community: all factors already in a client's life

before he or she arrives at your doorstep. They also include

serendipitous interactions between such inner strengths and

happenstance, such as a new job or a crisis successfully

negotiated. Wampold’s meta-analysis assigns 87% of the

variance to these so called extratherapeutic factors.

TIPS

� If you are not convinced that the

alliance should be central to your

ideas about change, consider the

Wampold (2001) meta-analytic

perspective of the alliance.

� He portions 54% of the variance

attributed to the impact of

intervention to the alliance.

� Putting this into perspective, the

amount of change attributable to

the alliance is about seven times

that of specific model or

technique.

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Next to what clients bring, their perceptions of the

relationship with you are responsible for most of the gains

resulting from any helping endeavor. Now usually called

the "alliance," it is most easily understood as a partnership

between the client and helper predicated on a strong

agreement on the goals and tasks of therapy. Client's

favorable ratings of the alliance are the best predictors of

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success—more predictive than diagnosis, approach, therapist, or anything else.

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Expectancy refers to the portion of improvement deriving from clients' knowledge of being

helped, the instillation of hope, and how credible the client perceives your rationale and

techniques. These effects do not come specifically from a given treatment procedure; they come

from the hopeful expectations that accompany the method.

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Model/technique factors are the beliefs and procedures unique to specific treatments like the

miracle question in solution-focused therapy or challenging generalizations in cognitive-

behavioral therapy or confrontation in twelve-step work. Despite all the hoopla around the power

of models, it is worthy to note that not one has demonstrated any superiority over any other—this

is the so-called “dodo bird verdict” (“All have won and all must have prizes” from Alice in

Wonderland). The verdict colorfully summarizes that approaches work about the same and points

to elements common across models that better explain successful outcomes—namely the innate

resources of the client, the quality of the relationship, and the hope for a better future. How

exactly should models be viewed when so much of good clinical work is controlled by other

factors—85% to be exact (40% client factors, 30% relationship factors, and 15% expectancy

factors)? Read on.

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1. Develop a change-focus.

� Listen for a change--whenever and for whatever reason it occurs. Ask about what, if any,

changes clients have noticed since the time they scheduled their appointment. (monitor

and measure change)

Many people notice that, between the time they called for the appointment and the actual first session, things already seem different. What have you noticed about your situation?

� Listen for key words that reflect change. When clients say:

Thing have been really bad until recently; He is failing all of his classes except math.

Take notice and follow up.

� Ask about change between sessions.

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What is different since our last meeting? What is better?

!!!!!!!!!!!

2. Listen for heroic stories.

� The key here is the

attitude you assume

regarding your

client’s inherent

abilities—you must

foster a determined

mindfulness to find

competencies,

strengths, resiliencies,

and resources that

you know are there.

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TIPS Consider these questions for clients:

1. What are the traits, qualities, and characteristics that

describe you when you are at your very best? What were you

doing when these aspects became apparent to you?

2. What kind of person do these aspects describe?

3. What are the traits, qualities, and characteristics that others

would describe in you when you are at your very best? What

were you doing when they noticed these aspects in you?

4. What kind of person do these aspects describe?

5. 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?

6. Who was the last person to tell you that they noticed the best

of you in action? What were you doing when they noticed

these aspects?

7. Who in your life wouldn’t be surprised to see you stand up to

these situations and prevail? What experiences of you would

they draw upon to make this conclusion??

8. When I am at my very best, I am

______________________________________.

Consider these questions for therapists:

� What are the obvious and hidden strengths, resources,

resiliencies, and competences contained in the client’s story?

� What are the competing stories that can be told—the stories

of clarity, coping, endurance, and desire that exist

simultaneously with the stories of confusion, pain, suffering,

and desperation?

� What is already there to be recruited for change?

� This does not mean

that you must ignore

pain or assume a

Pollyanna stance.

Rather, it only

requires that you give

voice to the whole

story: the confusion

and the clarity; the

suffering and the

endurance; the pain

and the coping; the

desperation and the

desire.

� The stories of who we

are have multiple

sides, depending on

who is recounting

them and what sides


are emphasized. Unfortunately, the Killer Ds (diagnosis, dysfunction, disorder, disease,

deficit) have persuaded us to believe in the story of pathology as the only or best version.

It is neither. Many others of survival and courage simultaneously exist—help your clients

tell stories that portray their courage and heroism.

3. Validate the client's contribution to change.

� When change happens, ask clients to elaborate the change and their contribution to it.

What was happening at those times? What do you think you were doing to help that along? What would you need to do (or what would need to happen) to experience more of that? As you continue to do these good things for yourself (or take advantage of what is helping), what difference will that make tomorrow? How will your day go better? The day after?

� Link the positive change to the client’s

own behavior. Even if clients attribute

change to luck, fate, you, or a

medication they can still be asked: (1)

how they adopted the change in their

lives, (2) what they did to use the

changes to their benefit, and (3) what

they will do in the future to ensure their

gains remain in place.

Wait a second. You did what? Tell me more. How did you know to do what you did? That was thoughtful. What is it about you that helped you to do what you did? What does it say about you that you took advantage of the medication at this time? What part of you was lying dormant, ready to come out that the medication gave a boost to?

TIPS Telling Heroic Stories:

� Think of a time in your life that was very difficult, but you managed to get through it.

� What personal resources did you draw on to get through this difficulty?

� What family, spiritual, friend, or community support did you draw on to get through?

� What does this story tell about who you are and what you can do?

� Who else knows this story about you? � What do you think they say this story says

about who you are and what you are capable of?

4. Tap into the client’s world. Whether seeking out a trusted friend or family member,

purchasing a book or tape, attending church or a mutual-help group, clients find support outside

of your agency.

� Listen for and then be curious about what happens in the client's life that is helpful.

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� Inquire about the helpful aspects of the client's social support network, activities that

provide relief, even if

temporary, and circumstances

in which the client feels most

capable, successful, and

composed.

� Identify not what clients need,

but what they already have in

their world that can be put to

use in reaching their goals

Whom does the client refer to as helpful in his or her day-to-day life? How or what does the client do to get these persons to help him or her? What persons, places, or things does the client seek out between sessions for even a small measure of comfort or aid? What persons, places, or things has the client sought out in the past that were useful? What was different about those times that enabled the client to use those resources?

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1. Court the client's favor and woo

their participation—fit their ideas

of a good relationship

� Carefully monitor the client’s

reaction to comments,

explanations, interpretations,

questions and suggestions.

Use the client’s language—their words, ideas, and expressions. Stay close to their

descriptions of their lives. (Monitor and measure the alliance.)

TIPS Validation requires you to accept your client at face value and

search for justification of his or her experience—replacing the

invalidation that may be a part of it. Ask yourself the following

questions about the client’s story:

• What are the obvious and hidden invalidations contained in

the client’s story? How is the client or others discounting or

contradicting his or her experiences? How is he or she or

others blaming the client for this situation?

• What other factors or circumstances have contributed to

this situation or are extenuating or mitigating variables?

How can I place the client’s situation in a context that

explains and justifies his or her behavior or feelings? How

can I give the client credit for trying to do the right thing?

• How is this experience representative of an important

crossroad in the client’s life or a statement about his or her

identity? What message is the client’s internal wisdom

attempting to express?

• Put the client’s experience in the following format:

No wonder you feel or behave this way (fill in with client

circumstance) given that (fill in the ways you have discovered to

justify his or her responses).

Finally:

• Now that the client is validated, what different conclusions

are reached? Did any other courses of action emerge?

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� Be flexible. Some clients will prefer a formal or professional manner over a casual or

warmer one. Others might prefer more self-disclosure from their therapist, greater

directiveness, a focus on their symptoms or a focus on the possible meanings beneath

them, a faster or perhaps, a more laid back pace for therapeutic work. The one-approach-

fits-all strategy is guaranteed to undermine alliance formation. You are

multidimensional—you are already many things to many people (friend, partner, parent,

child, sibling). Use your complexity to fit clients! (Monitor and measure the alliance.)

� Validate the client. Validation occurs when client’s thoughts, feelings, and behaviors are

accepted, believed, and considered completely understandable given trying

circumstances. Legitimize the client’s concerns and highlight the importance of the

client’s struggle.

2. Accept client goals at face value.

� Work on client goals, period.

� Listen and then amplify the stories and experiences that clients offer about their

problems, including their thoughts, feelings, and ideas about “where they want to go and

the best way to get there.” (Monitor and measure the alliance.)

� Ask directly about the client’s goals.

What is your goal for treatment? What did you (hope/wish/think) would be different because of coming here? What did you want to change about your (life/problem/etc.)? What would have to be minimally different to consider our work together a success? What will be the first sign to you that you have taken a solid step on the road to improvement even though you might not yet be out of the woods?

3. Form all plans and tasks with the client. Fit the client’s theory of change (Monitor and

measure the alliance.)

� Change is done with rather than to the client (e.g., fill out a genogram, take this

medication, go into trance).

� In a good alliance, helpers and clients jointly work to construct interventions that are in

accordance with clients’ preferred outcomes. In this light, interventions represent an

instance of the alliance in action. They cannot be separated from the client’s goals or the

relationship in which they occur.

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1. Believe in the client, in yourself and your work, and in the probability of change.

� Show your faith in the client and your trust in your services. Know that no matter how

troubling the client’s situation is, that it will change.

� Show interest in the results of whatever technique you employ. Ask about the beneficial

effects of the therapy at some point during each session. Ask clients to notice and record

any changes for the better that occur between sessions. Convey hope for and expectation

of improvement.

2. Orient therapy toward a hopeful future. Clients are best served by helping them believe in

possibilities—of change, of accomplishing or getting what they want, of starting over, of

succeeding or controlling their life.

� Facilitate hope and positive expectations for change by exploring the pessimistic

assumptions clients have

about the future. Ask

questions to assist clients in

envisioning a better future:

What will be different when (anxiety, drinking, feuding with others, etc.) is behind you? What will be the smallest sign that it’s getting better? What will be the first sign? When you no longer spend so much time struggling with (______), what will you be doing more of or instead? Who will be the first person to notice that you have achieved a victory? What will that person notice different that will tell him or her that the victory is achieved? Where do suppose you will be when you first noticed the changes? What will have taken place just before the changes that will have helped them to happen?

TIPS Choose an approach by asking yourself these questions:

� Does the particular strategy capitalize on client strengths,

resources, and abilities?

� Does the orientation/intervention use the client’s existing

support network?

� Does the method identify or build on the changes clients

experience while in therapy?

� Would the client describe the therapeutic interaction resulting

from the adoption of the particular strategy or orientation as

empathic, respectful, and genuine?

� Does the orientation/technique identify, fit with, or build on the

client’s goals for therapy?

� Does the orientation or strategy fit with, support, or

complement the client’s world view and theory of change?

� Does the theory or intervention fit with the client’s expectations

for therapy?

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What will happen later that will help maintain them?

3. Highlight the client’s sense of personal control.

� People who believe they can influence or modify the course of life events cope better and

adjust more successfully. Ask questions that presuppose client influence over events

occurring in his/her life.

It is impressive that you took that step on your own to let the depression know who’s boss. When did it occur to you that that was the right thing to do? Now that you have done this, what else will you do to keep the depression on a short leash?

� Connect with or draw upon a previously successful experience of the client. This shines a

spotlight on the client’s agency and enhances hope for a different future.

Have you ever faced anything like this before? What happened? How did you do that? What were the steps you went through? Who did you involve? Can you do any of those things now?

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1. Use models to provide structure and focus.

� One of the best predictors of negative outcome is a lack of focus and structure.

� Find a structure that fits the client’s goals and preferences. All models, although the talk

differs, prepare clients to take some action to help them do something different, whether

developing new understandings, feeling emotion, facing fears, taking risks, or altering old

patterns of behavior.

� View techniques as something akin to a magnifying glass. They bring together, focus and

concentrate the forces of change, narrow them to a point in place and time, and cause

them to ignite into action.

2. Use a model to change your mind, not make up your mind, about a client

� Models and techniques provide alternative ways of thinking and acting when change isn’t

happening—they provide novelty. With over 400 models and techniques to choose from,

little reason exists for continued allegiance to one when it fails. Instead, another model or

technique can be considered.

� Do something different when you fail to hear reports of progress within a few hours

rather than months of therapy. Change your mind earlier rather than later. The most

frequent improvement occurs early with a course of diminishing returns thereafter.

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3. Use technique as a vehicle for enhancing the effects of the other common factors.

� Use the common factors to choose alternatives. Orientations that help you adopt a

different way to identify or approach clients’ goals, establish a better match with clients’

ideas, foster hope, capitalize on clients’ strengths, and utilize environmental supports are

likely to prove the most beneficial.

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� Make direct inquiries about the client’s goals and

ideas about change:

What did you (hope/wish/think) would be different as a result of coming here? What did you want to change about your (life/problem/etc.)? What would be minimally different in your life to consider our work together a success?

TIPS

� The client’s theory of change

unfolds from a conversation

structured by your curiosity about

the client’s ideas, attitudes, and

speculations about change.

� Honoring the client’s theory occurs

when you follow, encourage, and

implement the client’s ideas for

change or when you select a

technique or procedure that fits

clients’ beliefs about their

problem(s) and the change process.

� As the client’s theory evolves,

implement the client’s identified

solutions or seek an approach that

both fits the client’s theory and

provides possibilities for change.

What do you think would be helpful? What ideas do you have about what needs to happen for improvement to occur? Many times people have a pretty good hunch about not only what is causing a problem, but also what will resolve it. Do you have a theory of how change is going to happen here?

� Listen for or inquire about the client’s usual

method of, or experience with, change:

How does change usually happen? What causes change to occur?

What does the client do to initiate change? What do others do to initiate/facilitate change? What is the usual order of the change process?

What events usually precede/occur during/follow after the change?

� Discuss prior solutions as a way of learning the

client’s theory of change:

What have you tried to help the problem/situation so far? Did it help? How did it help? Why didn’t it help?

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Exploring solution attempts enables you to hear the client’s evaluation of previous attempts and

their fit with what the client believes to be helpful. Inquiring about prior solutions, therefore,

allows you to hear the client’s frank appraisal of how change can occur.

� Find out what your role is in the change process:

How does the client view your part in the change process? Clients want different things. Some

want a sounding board, some want a confidant, some want to brainstorm and problem solve, some

want advice, some want an expert to tell them what to do. Explore the client’s preferences about

your role by asking:

How do you see me fitting into what you would like to see happen? How can I be of most help to you now? What role do you see me playing in your endeavor to change this situation? Let me make sure I am getting this right. Are you looking for suggestions from me about that situation?

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Just Do it! The first way to honor the client’s theory of change is really simple. Just find out what

the client’s ideas are and then, as the Nike ad says, just do it.

Clients often have good ideas about their situations but have not been allowed the space to

explore them with someone who believes in them. Trust client ideas and follow them to their

logical conclusion.

Make it so Number One. Recall in the adventure series Star Trek, how Captain Picard inevitably

turned to his first officer and said, “Make it so Number One!” This is akin to the process of

honoring the client’s theory of change. Sometimes clients discuss their own views of how change

will happen and identify what they need, but do not detail how they will make it happen or how

their views can be concretely implemented. This is your job as first officer.

You can fit the client’s views of change by thinking of approaches that seem to fit the situation

the client is describing or sound like the solution the client is talking about.

11


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D6%!M++C.!

Change early on in therapy is a good predictor of eventual outcome. Yes it’s true, if you can’t

get anything going by session 3, and for sure by session 6, then it is very likely at session 20, that

nothing will still be happening—if the client is still around. Partnering with clients to make

therapy accountable monitors the client’s view of progress to capitalize on this fact.

The client’s view of the relationship is a good predictor of outcome. In fact, the client’s rating

of alliance in the second session is the best predictor of success going. So if the client doesn’t like

you or what’s happening early on, then don’t look for much change, except of course if you call

dropping out an indication of change! Partnering with clients to make therapy accountable

monitors the client’s view of the process of therapy to capitalize on this fact.

D6%!O)C.!

About 10% of clients account for 60-70% of mental health care expenditures. We are

spending all our money on situations that are not changing. Go figure! Partnering with clients to

make therapy accountable turns this situation around, opening options for both clients and

therapists by providing immediate feedback when things are stuck.

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Therapists who are not getting positive results often believe that their therapy is effective.

Yes, it’s sad but true, research shows that the helper is the last to know. Partnering with clients to

make therapy accountable let’s us know when, and often why, we are not effective. This

information need not be painful, but rather is liberating in terms of helping us do better work.

Enlisting the client makes being a helper much easier.

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Real time feedback about the outcome of services can up to double effectiveness. Research of

real world outpatient settings has shown that on average, only a paltry 35% of clients improve or

recover. Therapists range from about 20 to 70% in effectiveness. However, when therapists are

14


given reliable feedback about whether or not clients are reporting benefit, effectiveness rates

increase dramatically. No one is effective with everyone—even the best among us are not

successful with almost a third of our clients. Finding this out early rather than late prevents

ongoing ineffective work and encourages better options for the client. Our research showed that

real time feedback doubled therapist effectiveness! Other studies show up to a 65% increase in

effectiveness.

Outcome management offers an alternative to burdensome and meaningless paperwork. For

years, counselors have endured heavier and heavier burdens of paperwork. Now there is an

alternative. Imagine this: Partnering with clients to monitor process and outcome on just two brief

forms is the only paperwork required—that’s right, no more diagnostic workups, treatment plans,

intake forms, or any other form or practice that doesn’t have any relevance to outcome. You say

I’m a dreamer, but I’m not the only one! It’s already happening in some places. Partnering with

clients to make services accountable is already, and will continue, changing the way that mental

health services are delivered. Start now!

Becoming Outcome Informed In the first contact, you want to:

1. Convey commitment toward improving client’s situation

2. Convey commitment to the highest quality of care

3. Begin partnering process

Ex. We are very concerned about whether you reach your goals at our agency. For this

reason, it is very important that you are involved in monitoring our progress. We will make

all the decisions regarding your situation together. I monitor my effectiveness with every

client through the use of brief forms. These take only a couple minutes to fill out but yield a

great deal of information about how things are going. I will give you one in the beginning of

the session and one toward the end. This will allow us to monitor your change and my

effectiveness throughout the course of our work together. I will explain this in greater detail

when you arrive for your first session. If you would, please arrive 15 minutes early for your

first session. This will give us time to fill out our intake forms without using any of our

session time. Shall we schedule your appointment? Great!

15


Initial Session:

Step 1: Introducing the ORS

Ex. During the course of our work together, we will be giving you very short forms

asking you how you think things are going and whether you think things are on track. We

believe that to make the most of our time together and get the best outcome, it is

important to make sure we are on the same page with one another about how you are

doing, how we are doing, and where we are going. We will be using your answers to keep

us on track. Will that be okay with you?

Ex. Before we start I will greatly appreciate it if you would fill out the following form for

me. The lines on this form measure the extent to which different life challenges may be

impacting you at this time. Your answers would help me get a picture of the struggles that

you may be facing at this time. While filling out this form keep in mind the events that

have occurred in your life within the last week to the present time and the experiences

you have had during that time.

Ex. I’d like to introduce you to something I like to do when working with clients. This is

called the ORS. Did our intake person mention it to you? Good! Let me just take a

moment to provide you with a little more information about it. The ORS is an outcome

measure that allows me 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 I am being helpful. That is

very important to me. In a way this is monitoring both of us. I use this because I want to

ensure that I am providing you with the best services possible. 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? Great!

Step 2: Incorporating the ORS

The idea here is simple. The ORS provides an anchor of where the client is and allows a

comparison point for later meetings. It involves the client in a joint effort to observe progress

toward goals.

Ex. From your ORS, it looks like you’re experiencing some real problems, or, From

your scores, it looks like you’re feeling okay; what brings you here today? Or, if you like

numbers more, Your total score is 15—wow, that’s pretty low. A score of 24 or lower

indicates people who are in enough distress to seek help. Things must be pretty tough for

you.

Ex. The way this ORS works is that marks toward the left indicate that things are hard

for you now or you are hurting enough to bring you to therapy. Your score indicates that

you are really having a hard time. Would you like to tell me about it? Or if all the marks

16


are to the right, Generally ,when most people make their marks so far to the right, it is an

indication that things are going well for them. It would be really helpful for me to get an

understanding of what it is that brought you to therapy at this point in time?

Ex. And/or at some point in the meeting, you pick up on the client’s comments and

connect them to the ORS: Oh, okay, sounds like dealing with the loss of your brother is

an important part of what we are doing here. Is the distress from that situation account

for your mark here on the ORS? Okay, so what do you think will need to happen for that

mark to move toward the right?

Your interest in the client’s desired outcome speaks volumes to the client about your commitment

to them and the quality of service they receive.

Step 3: Introducing the SRS

Ex. During the session, we will take a short break in which I will give you another form

that gives your opinion of our work together and if I am meeting your expectations. This

information helps me stay on track. The ultimate purpose of using these forms is to make

every possible effort to make coming to see me a beneficial experience for you. I need

your help in making sure that I stay on the same page with you. Would that be okay with

you?

Ex. Before we wrap up tonight I would like you to fill out another short questionnaire.

This one deals directly with how I am doing. It is very important to me that I am meeting

your needs. A lot of research has shown that how well we work together directly relates

to how well things go. If you could take a moment to fill it out, I will discuss it with you

before you leave. Great, thanks

Step 4: Incorporating the SRS

At the end of the session during the final message or summary process, incorporate the SRS

responses. The SRS is easily scored by measuring the client’s marks on the line in a similar

fashion as the ORS. Each line is 10 centimeters long. Just pick up on an item or two on the SRS

and make comment on it. If there are any scores lower than 9 centimeters, follow up on it.

Generally speaking, a total score of 36 or less should be discussed. The best thing that the SRS

can do for you is to allow you to fix any alliance problems that are developing. The SRS shows

clients that you do more than talk the talk—you are REALLY interested in their feedback and

want to know what they think.

Ex. Let me just take a second here to look at this SRS—it kind of like a thermometer that

takes the temperature of our meeting here today. Wow, great, it looks good, looks like we

17


are on the same page, that we are talking about what you think is important and you

believe today’s meeting was right for you.

Ex. Let me quickly look at this other form here that let’s me know how you think we are

doing. Okay, seems like I am missing the boat here. Was there something else I should

have asked you about or should have done to make this meeting work better for you?

What was missing here?

Just bringing up any problems and your willingness to be flexible and nondefensive speaks reams

to the client and usually turns things around quickly. This process is repeated in every session.

Follow up Sessions: Checking for Change

Okay, you got the idea. Now it gets interesting. Here is where you get down to the business of

being outcome-informed—the client’s view of progress really influences what you do.

� Greet clients and provide them with the ORS to complete. You may also have a folder with

blank forms available in your waiting room.

� Compare this session’s ORS with the previous one and look for any changes.

� Is there an improvement (a move to the right), a slide (a move to the left), or no change of

any kind? Is there an increase in the total score of at least 5, or an increase to a total of 25 or

more? Is there a decrease or no change at all?

� Present the change or absence of change and engage the client in a discussion about their

marks or scores.

Ex. Holy cow! Wow, your mark on the personal well-being line really moved—about 3

centimeters to the right! What happened? How did you pull that off?…This kind of change is

called a reliable change and may mean that it’s time for us to reevaluate. Where do you think

we should go from here? Or, Look, your total increased by 8 points to 29 points. That’s quite

a jump!

Refer above to eliciting change talk about asking questions about the noted changes.

Ex. Okay, so things haven’t changed since the last time we talked. How do you make sense

of that? Should we be doing something different here or should we continue on course

steady as we go?

Again the idea is that the client is involved in the process of monitoring progress and the decision

about what to do next. Implementing process and outcome measures gives helpers, consumers,

and third party payers a different and reliable way to maximize time, effort, and results.

18


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Use the child measures in a similar fashion to the adult measures. There are some differences:

� When the child is presented as the problem, use the CORS with the child and parents; do

not obtain ORS scores of the parents unless they identify separate problems for

themselves.

� The measures encourage conversations about similarities and differences; and they allow

therapists to attend to each person’s perspective of both change and the alliance. They

provide a common ground on which to make comparisons and draw distinctions,

allowing each individual to be part of the discussion of what needs to happen next.

� It is not unusual for families to hold different perspectives. Using a graph with different-

colored lines for each person helps illustrate varying viewpoints and can open up a

productive conversation.

� The CSRS and SRS give therapists a chance to see which, if any, family members are

feeling the least connected to the process. The therapist then has accurate knowledge of

where to focus more attention. Using the CORS and ORS with families is an invaluable

way to keep track of many change trajectories and many agendas—all it takes is a

willingness on the therapist’s part to become adept at seamless data gathering for several

people in session and the ability to make that information meaningful by using it as a

springboard for conversation. The reward is the same, whether child or family—reliable

feedback about whether things are changing and the strength of the alliance, so

counseling can better fit client preferences for the best outcome.

Brief Bio: Barry L. Duncan, Psy.D., therapist, trainer, and researcher, with over 17,000 hours of face to face experience with clients, and is co Director of the Institute for the Study of Therapeutic Change (ISTC). Barry has over one hundred publications, including fourteen books. His latest: The Heroic Client (2nd edition) (Jossey Bass, 2004) offers both a critique of mental health practice and suggests an alternative based in outcome management; Heroic Clients, Heroic Agencies: Partners for Change (ISTC Press, 2002; 2007 Revised E Version at www.talkingcure.com), details the “how tos” of involving clients as valued partners in transforming mental health and substance abuse services; and finally, Brief Intervention for School Problems (Guilford Press, 2007) applies client directed, outcome informed practice in school settings. Because of his self help books, he has appeared on "Oprah,” “The View," and several other national TV programs. His latest self help book, What’s Right With You, challenges the business as usual mentality of “What’s wrong with you” and instead demonstrates how to rally natural resources to overcome life challenges. Barry conducts seminars internationally in client directed, outcome informed therapies.

19

Outcome Rating Scale (ORS)

Name ________________________Age (Yrs):____ Sex: M / F Session # ____ Date: ________________________ Who is filling out this form? Please check one: Self_______ Other_______ If other, what is your relationship to this person? ____________________________

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

The Heart and Soul of Chang Project _______________________________________

www.heartandsoulofchange.com

© 2000, Scott D. Miller and Barry L. Duncan

40

35

30

25

20

15

10

5

0

Session Number 1 2 3 4 5 6 7 8 9 10

ORS Cutoff

SRS Cutoff

Discuss

Session Rating Scale (SRS V.3.0)

Name ________________________Age (Yrs):____ ID# _________________________ Sex: M / F Session # ____ Date: ________________________

Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience.

Relationship

I-------------------------------------------------------------------------I

Goals and Topics

I------------------------------------------------------------------------I

Approach or Method

I-------------------------------------------------------------------------I

Overall

I------------------------------------------------------------------------I

The Heart and Soul of Change Project _______________________________________


© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson

I felt heard, understood, and

respected.

I did not feel heard, understood, and

respected.

We worked on and talked about what I

wanted to work on and talk about.

We did not work on or talk about what I


Overall, today’s session was right for

me.

There was something missing in the session

today.

The therapist’s approach is a good fit

for me.

The therapist’s approach is not a good

fit for me.

Group Session Rating Scale (GSRS)

Name ________________________Age (Yrs):____ ID# _________________________ Sex: M / F Session # ____ Date: ________________________

Please rate today’s group by placing a mark on the line nearest to the description that best fits your experience.

Relationship

I----------------------------------------------------------------------I

Goals and Topics

I----------------------------------------------------------------------I

Approach or Method

I----------------------------------------------------------------------I

Overall

I----------------------------------------------------------------------I

The Heart and Soul of Change Project _______________________________________


© 2007, Barry L. Duncan and Scott D. Miller

I felt understood, respected, and

accepted by the leader and the group.

I did not feel understood, respected, and/or

accepted by the leader and/or the group.

We worked on and talked about what I


We did not work on or talk about what I


Overall, today’s group was right for me—I felt like a part of the group.

There was something missing in group

today—I did not feel like a part of the group.

The leader and the group’s approach are

a good fit for me.

The leader and/or the group’s approach are/is

not a good fit for me.


ORS and SRS Graph

40

35

30

25

20

15

10

5

0

Session Number 1 2 3 4 5 6 7 8 9 10

A.S.I.S.T.

The computerized, Administration, Scoring, Interpretation, and data Storage Tool

for the Outcome Rating Scale (ORS) and Session Rating Scale (SRS)

Looking for a simple, valid, reliable and automated way to monitor and improve the outcome of you clinical work? The ASIST program is a easy to use, end-user software program that administers, scores, interprets, and stores scores from the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS). ASIST also provides therapists with "real time" feedback regarding their client's experience of the alliance and progress in treatment. Using a sophisticated set of algorithms based on years of research and a large normative sample, the program helps clinicians identify clients who are making progress and those "at risk" for a negative outcome or drop out.

ASIST enables you to:

Administer, Score, Interpret, and Store the ORS and SRS Receive "real time" feedback regarding client progress and experience of the alliance

Identify which clients are making progress and which are "at risk" for a negative outcome or drop out

Determine your overall effectiveness relative to a national sample of practitioners For more info and to purchase, visit www.talkingcure.com

ORS Cutoff

Discuss

SRS Cutoff

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