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www.heartandsoulofchange.com September 14, 2012
The Art & Science of Becoming a Better Therapist
The Nuances of the Outcome Rating Scale
Barry Duncan, Barry Duncan, Psy.DPsy.D. . www.heartandsoulofchange.comwww.heartandsoulofchange.com561.239.3640 [email protected] [email protected]
www.heartandsoulofchange.com September 14, 2012
Winter Getaway!Training of Trainers
Winter Getaway!Training of Trainers
HSCP Training of Trainers HSCP Training of Trainers Conference: January 28-Feb. 1, 2013 (27 CEUs) This intensive training experience gives you all you need to train others and
Conference: January 28-Feb. 1, 2013 (27 CEUs) This intensive training experience gives you all you need to train others andneed to train others and implement CDOI and PCOMS. And it provides the first step in becoming an HSCP Certified Trainer.
need to train others and implement CDOI and PCOMS. And it provides the first step in becoming an HSCP Certified Trainer.
www.heartandsoulofchange.com September 14, 2012
What’s UpNuances of Using the ORS
What’s UpNuances of Using the ORS
How to introduce theHow to introduce theHow to introduce the Outcome Rating Scale, to validate the client via the clinical cutoff, to connect the client’s marks to his or
How to introduce the Outcome Rating Scale, to validate the client via the clinical cutoff, to connect the client’s marks to his orthe client s marks to his or her described experience/ reasons for service, and toensure a good rating.
the client s marks to his or her described experience/ reasons for service, and toensure a good rating.
Getting the Max Out of the Measures Just the Facts Ma’am
Getting the Max Out of the Measures Just the Facts Ma’am
The nuts & bolts & The nuts & bolts & The nuts & bolts, & the nuances, more to it, clinically, than it looksF db k i h
The nuts & bolts, & the nuances, more to it, clinically, than it looksF db k i h Feedback is the way to transcend average.
Feedback is the way to transcend average.
www.heartandsoulofchange.com September 14, 2012
The Measures and Social Justice“Leveling” the Counseling ProcessThe Measures and Social Justice
“Leveling” the Counseling Process
Invites clients into inner Invites clients into innercircle of decision making
Available in multiple languages
Voice to diversity and the
circle of decision making Available in multiple
languages Voice to diversity and they
disenfranchised Local culture and context
over privileged knowledge
ydisenfranchised
Local culture and contextover privileged knowledge
Cli t’ ti f thti f th
Starting With Starting With the Predictorsthe PredictorsChange and the Alliance
•Client’s rating of the rating of the alliancealliance the best predictor of the best predictor of engagement and outcome.engagement and outcome.
•Client’s subjective subjective experience of change earlyexperience of change earlyexperience of change early experience of change early in the process the best in the process the best predictor of success for any predictor of success for any particular pairing.particular pairing.
www.heartandsoulofchange.com September 14, 2012
Who drops out?
Sooner Rather Than Later
A
B
•The bulk of change occurs sooner rather than
Howard, K. et al. (1986). The dose-effect response in psychotherapy. American Psychologist, 41, 159-164.
rather than latter
Some clients do take longer, but the mythology never dies
N=4676; 77% attended 8 or less, and 91% 12 or less
Note that even for the clients who take longer, change starts early just is
Baldwin, S., Berkeljon, A., Atkins, D., Olsen, J., & Nielsen, S. (2009). Rates of change in naturalistic psychotherapy: Contrasting dose-effect and good-enough level models of change. Journal of Consulting and Clinical Psychology, 77(2), 203-211.
change starts early…just is flatter
www.heartandsoulofchange.com September 14, 2012
Cannabis Youth Treatment ProjectEarly change in
It’s A FactEarly Change is The Rule
Project MATCH
y gtreatment is a robust predictor of outcome and retention in treatment
http://www.chestnut.org/LI/Posters/CYT_%20MF_APA.pdfBabor, T.F., & DelBoca, F.K. (eds.) (2003). Treatment Matching in Alcoholism. United Kingdom: Cambridge, 113.
treatment.Gotta measure outcome!
•Give at the beginning of the visit
•Client clicks a mark on the line
•Scored to the nearest millimeter
•Each line 10 cm (100 mm) in length
•Four scales added for the total score
www.heartandsoulofchange.com September 14, 2012
The ORS Is Not ThisThe ORS Is Not This
The ORS Is Different ThanOther Outcome MeasuresThe ORS Is Different ThanOther Outcome Measures
Co-constructed with client
Co-constructed with clientclient
Goes from general look at client distress to specific representation of
client Goes from general
look at client distress to specific representation of pclient’s experience & reason for service
Requires nuance & skill in application
pclient’s experience & reason for service
Requires nuance & skill in application
www.heartandsoulofchange.com September 14, 2012
Co-Constructed With ClientCo-Constructed With Client
To Be Relevant To Be Relevant to Therapeutic Process
To Have Meaning from
to Therapeutic Process
To Have Meaning fromMeaning from the Client’s Understanding of His or Her Life
Meaning from the Client’s Understanding of His or Her Life
•When scheduling, provide
Becoming Better Creating A Culture of Feedback
Becoming Better Creating A Culture of Feedback
rationale for seeking feedback; convey commitment to their goals and highest quality of service…in your own words •Work a little differently;•If we are going to be helpful•If we are going to be helpful should see signs sooner rather than later; If not helpful, we’ll seek consultation & consider a referral.•No one has ever said: Bad idea!
www.heartandsoulofchange.com September 14, 2012
The Outcome Rating ScaleAn Introduction
The Outcome Rating ScaleAn Introduction
The ORS is an outcome measure that allows t t k h ’ t h ’ d i
The ORS is an outcome measure that allows t t k h ’ t h ’ d ius 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 h th t dd i h t thi k i
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 h th t dd i h t thi k ihere, 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?
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?
Introducing the ORS: Clip 1In Your Own Words
Introducing the ORS: Clip 1In Your Own Words
Convey theConvey theConvey the notion of monitoring outcome and
Convey the notion of monitoring outcome andoutcome and ensuring client voice is heard
outcome and ensuring client voice is heard
www.heartandsoulofchange.com September 14, 2012
The First SessionWhatever It TakesThe First Session
Whatever It Takes You can’t over-explain… You can’t over-explain… Clients get this. Face validity. Whatever explanation the
client gives is ok. Some will say: “You mean like poor to well?” or “Like 1 to 10?”
Clients get this. Face validity. Whatever explanation the
client gives is ok. Some will say: “You mean like poor to well?” or “Like 1 to 10?”well? or Like 1 to 10?
It’s their subjective experience that matters so their understanding of the measure is paramount.
well? or Like 1 to 10? It’s their subjective
experience that matters so their understanding of the measure is paramount.
Idiosyncratic ResponsesNo Worries
Idiosyncratic ResponsesNo Worries
Sometimes ? re scales, or how th t 2 t f
Sometimes ? re scales, or how th t 2 t fthey rate 2 aspects of same scale: “Doing great with my kids, but my marriage stinks.”
“Rate what is relevant: “Are either of the topics related to why you are here? (Client says
they rate 2 aspects of same scale: “Doing great with my kids, but my marriage stinks.”
“Rate what is relevant: “Are either of the topics related to why you are here? (Client sayswhy you are here? (Client says here b/c of relationship with partner…Okay, rate the Interpersonally scale to reflect your concerns there.
why you are here? (Client says here b/c of relationship with partner…Okay, rate the Interpersonally scale to reflect your concerns there.
www.heartandsoulofchange.com September 14, 2012
The First MeetingThe “Clinical Cutoff”
The First MeetingThe “Clinical Cutoff”
40••The dividing line The dividing line
510152025303540
Out
com
eSc
ore
between a clinical & between a clinical & “non“non--clinical” clinical” population (25). For population (25). For kids kids (32) & adolescents(32) & adolescents(28) t k (28)(28) t k (28)
05
1st 2nd 3rd 4th
Session Number
Actual Score Line 2 25th % 75th %
(28); caretakers (28) (28); caretakers (28) ••Between 25Between 25--33% 33% score in the “nonscore in the “non--clinical” range.clinical” range.
The Clinical CutoffOnly 2 Choices
The Clinical CutoffOnly 2 Choices
Either above or below. M ti li t it
Either above or below. M ti li t it Mention client score as it relates to the cutoff & have the client make sense of it.
Scores under cutoff may seem more straightforward
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. Looking for a change.
Reporting distress similar to others seeking services—the lower the score, the higher the distress. Looking for a change.
www.heartandsoulofchange.com September 14, 2012
40
Initial Information…Initial Information…
••Client’s score Client’s score
10
20
30
OR
S s
core
is withinis within the the clinical range.clinical range.
••Scoring more Scoring more like people inlike people intherapy andtherapy and
01 2 3 4 5 6 7 8 9 10
Session number
Projected change 75th percentile ORS Scores
Estimated Clinical Cutoff 25th percentile
therapy andtherapy andwantingwantingsomething tosomething tochangechange
The Clinical Cutoff: Clip 2The Clinical Cutoff: Clip 2Validating the Client’s Experience
••Everything is 100% Everything is 100% transparenttransparent••If really low score, say so If really low score, say so and validate how hard things and validate how hard things must bemust be••Start with the scale you Start with the scale you marked the lowest or start marked the lowest or start wherever you would likewherever you would like••Always a light touchAlways a light touch——never never heavyheavy--handed handed
www.heartandsoulofchange.com September 14, 2012
ORS: An ExampleORS: An Example
••What can we gleanWhat can we glean7.6
5.7
8.0
What can we glean What can we glean clinically clinically from this from this client’s scores in client’s scores in addition to being above addition to being above the clinical cut off?the clinical cut off?
7.5
Total = Total = 28.828.8
••How could we use this How could we use this information to begin or information to begin or focus the session?focus the session?
••Explore why the client entered Explore why the client entered
The First MeetingOver the Clinical Cutoff
The First MeetingOver the Clinical Cutoff
xplo e why the client ente edxplo e why the client ente edtherapy; circumscribed therapy; circumscribed problem or problem or mandated/coercedmandated/coerced••If mandated, ask for the referral’s If mandated, ask for the referral’s rating as a catalyst for rating as a catalyst for conversation; doesn’tconversation; doesn’t mean they aremean they areconversation; doesn t conversation; doesn t mean they aremean they arelyinglying••Avoid Avoid stirring the cauldron stirring the cauldron
www.heartandsoulofchange.com September 14, 2012
Take Clients at Face ValueTake Clients at Face Value
Please don’t interpret high Please don’t interpret high scores as a misrepresentation
It is the way the client sees him or herself
They don’t have to see a problem for therapy to help
scores as a misrepresentation It is the way the client sees
him or herself They don’t have to see a
problem for therapy to helpproblem for therapy to help Other’s ratings important too Just because it’s high doesn’t
mean they won’t engage
problem for therapy to help Other’s ratings important too Just because it’s high doesn’t
mean they won’t engage
First Session: Connect ORS to the Client’s Described Experience
First Session: Connect ORS to the Client’s Described Experience
At some point, connect the client’s described experience of their lives to the
At some point, connect the client’s described experience of their lives to theof their lives to the marks on the scalesof their lives to the marks on the scales
www.heartandsoulofchange.com September 14, 2012
The ORSThe Bare Bones
The ORSThe Bare Bones
No specific content other th d i k l t t
No specific content other th d i k l t tthan domains—a skeleton to which clients add the flesh & blood of their experiences.
At the moment clients connect the marks with what
than domains—a skeleton to which clients add the flesh & blood of their experiences.
At the moment clients connect the marks with whatconnect the marks with what they find distressing, the ORS becomes a meaningful measure of their progress and potent clinical tool.
connect the marks with what they find distressing, the ORS becomes a meaningful measure of their progress and potent clinical tool.
Has to be R l h
Has to be R l h
Integrating the MeasuresProblems and Challenges?
Relevant to the Work
Or Becomes an
Relevant to the Work
Or Becomes anOr Becomes an Emotional Thermometer of Day to Day Life
Or Becomes an Emotional Thermometer of Day to Day Life
www.heartandsoulofchange.com September 14, 2012
Get A Good RatingMake Sure
Get A Good RatingMake Sure
Transparency theTransparency theTransparency the rule, not confrontation/ judgment
Transparency the rule, not confrontation/ judgmentDarrell and Angelina JolieDarrell and Angelina Jolie
