Monitoring in family therapyHow to stay loyal to our dialogical

values?

Karine Van Tricht, Peter Rober & Rolf Sundet2nd Congress of the Open Network for Dialogical Practices

7-9 March 2013 Leuven, Belgium

Measure of process and outcome as conversational tools: Pathways to a

dialogical oriented practice of service user and therapist collaboration.

Rolf SundetLeuven, 2013

rosundet@online.no

University College of Buskerud,Institute for Research in Mental Health and Substance Abuse

&The Ambulant Family Section, Dept of Mental Health for Children and

Adolescents, Hospital of Drammen, Vestre Viken HF.

Mental Health Care anno 2013

• Neoliberal society – Market economy• Economic product• Profitability

o Moneyo Resultso Social benefit

• Psychotherapyo Evidence basedo Effectiveo Efficient

• ‘To measure is to know’ atmosphere• Quality Control Systems

From Evidence Based Practice to Practice Based Evidence

• RCT’s & Psychotherapyo Specificity & complexityo Generalizability?o External validity?o Creativity?

• RCT’s & Family Therapy = trouble in paradiseo What is the diagnosis?o Complexity and specificity of treatmento Who/what is responsible for change?

Monitoring: bridging the gap between research and practice

• Terminologyo Outcome managemento Routine Outcome Monitoringo Routine Outcome Measuremento Feedback Oriented therapyo Client Directed Outcome Informed Therapyo Trackingo Monitoringo ROMMENo QITTEN

Evidence• Outcome improvement

o Duncan & Sparks, 2009; 2010o Reese et al., 2010o Anker, Duncan & Sparks, 2009o Duncan & Miller, 2000

• Drop-out prevention & better dose/effect ratioo Lambert, 2007; 2010

• Experienced as useful and helpfulo Anker et al., 2011

• Leading to a better working allianceo Sundet 2010; 2011; 2012

Van Tricht & Rober

Monitoring as a way of working together

Dialogical space /

Culture of feedback

Creating Feedbac

k

Integrating

feedback

New way of

understanding

Go with the flow

Socially, cultural, religious, spiritual

Social (work, education, social contacts)

Family, close friends

Therapist(s), couple, parents,

children

The room of the therapist as a dialogical space in which a multitude of stories, opinions, emotions and perspectives come together

ClientSystem

Therapist System

Sources of inspiration (1)

Van Tricht, Van den Broeck, Rober, 2011; Rober 2012

Stinckens, Smits, Rober & Claes, 2012

Sources of inspiration (2)

• QIT online (Quality Improvement in Therapy)

Basic Principles

Characteristics

Instruments

Practice based Multidimensional

Psychometrics

Process oriented

Multimodal A-theoretical

Feedback driven

Flexibel Change sensitive

Broad spectrum

Internetbased Clinically relevantUser friendlyEasily available

A qualitative study of a locally developed family based practice

within Mental Health for Children and Adolescents

Conclusions: Two measures, the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS):

• They function as intended, that is; as tools of feedback.• A surplus: They function as conversational tools, that

is; they give rise and opportunity to conservational types and processes

Repairing an alliance burst by means of discussing feedback

Clinical conclusionThe ORS and the SRS do not give

answers, they are opportunities for questions

The family perspective:

The function of ORS & SRS as conversational

tools

To communicate

Tofocus

Tostructure

Toexplore

To tell and express

To visualize

To give direction to the work

To discover

To state areas of acceptance and change

To make distinct

To state thematic content

To deepen

The Therapist Perspective: The Function of ORS and SRS

as conversational tools

The scales as openings

...for conversations about feedback, progression and change...for conversations that express experiences, meanings, and perspectives about the therapeutic work...for conversations that create routine and structure...for conversations characterized by the not-knowing position...for externalizing conversations

...for conversations that bring forth a product or result

Van Tricht & Rober

Conceptual Framework QIT Family

Specificity of integrating monitoring in Family Therapy

• Instrumental levelo Adult & child versionso Outcome & process

• Implementational levelo Clear introduction o In session: Apart / togethero Home work: Apart / togethero On paper or electronic

• Dialogical levelo Open, curious, interested and non-judgmental T attitudeo Feedbackloops: how, what, wheno Enactment

Measurements of QIT Family [Informed Consent (Van Tricht & Rober, 2013)] Concerns Questionnaire (Van Tricht & Rober, 2013) SCORE-15 (Fay e.a., 2012; Stratton, subm. in JFT) OQ-45 (Lambert e.a., 1996) YOQ-30.2 (Burlingame & Lambert, 2001) ORS (Duncan & Miller, 2000) SRS (Duncan & Miller, 2000) (Y)CORS (Duncan, Miller & Sparks, 2003) (Y)CSRS (Duncan, Miller & Sparks, 2003) TSS(Kokotovic & Tracey, 1990; Tracey, 1989;

Hafkenscheid, 2012) IMI(Kiesler, 1996; Hafkenscheid, 2012)

Van Tricht & Rober

Feedback CULTURE In the relationship between service user and therapist, the

therapist perspective must be transparent and the service users perspective is given priority, especially in situations of no change or detrimental development

In the relationship between management and therapists the perspective of managers must be transparent and the therapist perspective must be given priority in each actual case.

The function of feedback is dependent upon allowing the therapists clinical autonomy in order to respond in a tailored manner to the feedback from the service users.

These measures are in danger of being ruined as feedback and conversational tools if they are included in a culture of competition and control

Thank you!

Alliances in Couple Therapy

• How to define the alliance in systemic therapies?• Dyadic relations / additional information?• Clinical relevance when there’s so much

confusion?• Overall conclusion:

o Positive correlation between working alliance and successful outcomeo Adding one more person adds multiple relationships

Muran & Barber, 2010

Alliances in Couple Therapy

• Individual model of the alliance + relational dynamics (Couple Alliance Scale, Pinsof & Catherall, 1984)o Alliances between each client and the therapist

• Direct self-reported alliance• Inferred alliance (guesses of the qual. & strenght of the partners’

rel. T)o Alliance between ‘clients-as-a-couple’ and the therapisto Relational (im)balances

• split alliances/siding/moving toward equilibrium

Muran & Barber, 2010

Muran & Barber, 2010

“An emerging quality of collaboration in

relation to the necessary accomplishments,

arising from a web of interacting relational

dynamics”

Gender

Gender

Motivation

Power Gender

Enactment

A Dialogically ORIENTED PRACTICE• including the voice, perspective, idea of the

other, that is; difference is included in the dialogical.

• to respond to the other and be responded by the other.

• to be embodied and embedded in social practices, that is; working with and in emotional transport and relational action

The practice• The use of conversational tools and the weight on

dialogue gives rise to a practice where reflection and meaning making are intertwined with emotional and experiential participation of the therapist

• The centrality of collaboration

Collaboration

Collaboration is characterized by;

Mutualism (turn-taking, jointly responding to the other’s response, dialogue, conversation)

Common goal Putting difference to work

Family based practice

”The helpful relationship”

”The helpful participation”

”The helpful conversation”

Generating collaboration (Alliance and to listen, take seriously and believe)

Using professional knowledge

Asking questions, giving time and structure the work

Giving of oneself Understanding through participation

Reformulation

Fighting violation, disparagement and degradation

Having many possibilities

Giving and receiving feedback

PublicationsSundet, R. (2010). Therapeutic collaboration and formalized feedback: Using perspectives from

Vygotsky and Bakhtin to shed light on practices in a family therapy unit, Clinical Child

Psychology and Psychiatry, 15(1), 81-95

Sundet, R. (2011). Collaboration: Family and therapists perspectives of helpful therapy. Journal of

Marital and Family Therapy, 37(2), 236-249

Sundet, R. (2012). Therapist perspectives on the use of feedback on process and outcome: Patient

focused research in practice. Canadian Psychology, 53(2), 122-130

Sundet, R (2012).  Patient focused research supported practices in an intensive family therapy unit:

What happens? Journal of Family Therapy, (Accepted for publication).

Sundet, R. (2012).  Postmodern-oriented practices and implementation of patient-focused research:

Possibilities and hazards. Australian and New Zealand Journal of Family Therapy (In review).