CLIENT-DIRECTED, OUTCOME-INFORMED TREATMENT Randy Walton, Ph.D. Licensed Clinical Psychologist/Lead Clinician Colonial Behavioral Health

Elements of Client-Directed, Outcome-Informed Treatment (CDOI)  Treatment effectiveness is based upon client goals and perceptions  Partnership between therapist and client  Regular, ongoing client feedback Effectiveness Effectiveness “Fit” between client and therapist “Fit” between client and therapist  Treatment adjusted based upon client feedback

QUIZ Q: Is psychotherapy effective? A: Yes  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?  However, research demonstrates particular areas in which therapists can improve  Dropout rates average about 50% (U.S., Canada, U.K.)  About 10% of clients do not improve, or deteriorate, while in treatment  Therapists frequently fail to identify failing cases  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  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  When the ORS and SRS are used each session  Clients are empowered and their voice is privileged  Clients are more engaged in therapy as a mutual endeavor  Clients can identify times when there is a problem in either:  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  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  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 “Extra-therapeutic” Factors (40%) “Extra-therapeutic” Factors (40%) Therapeutic Alliance (30%) Therapeutic Alliance (30%) Therapy Model or Technique (15%) Therapy Model or Technique (15%) Placebo Effect (15%) Placebo Effect (15%) Hubble, Duncan, Miller 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%) “Extra-therapeutic” Factors (87%) Therapeutic Factors (13%) Therapeutic Factors (13%) Therapeutic Alliance (8%) Therapeutic Alliance (8%) Therapeutic Allegiance (4%) Therapeutic Allegiance (4%) Therapy model or technique (1%) Therapy model or technique (1%) Wampold, B.E 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  Virtually all psychotherapy models and techniques are effective with some people, some of the time  Differences in outcome between models is consistently small or negligible  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  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”:  The client’s:  View of the problem  View of the change process  Goals and expectations  Desired pace for treatment

CDOI: The Client is Central  The capacity for self understanding, problem-solving, and growth, resides primarily in the client  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 Research shows that therapists are remarkably bad at judging whether a client is making progress in psychotherapy. Research shows that therapists are remarkably bad at judging whether a client is making progress in psychotherapy. 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. 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. 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]  “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.”  “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]  “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?  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.  Therapeutic processes, models, and techniques are not well informed and directed by:  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 Use of rating scales for ongoing feedback Use of rating scales for ongoing feedback  Outcome Rating Scale (ORS)  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  Session Rating Scale (SRS)  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: These scales, along with the administration and scoring manual, are available for free download and printing:

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 IInterpersonally (Family, close relationships) I ISocially (Work, school, friendships) I IOverall (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. RelationshipI 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. Approach or Method I I The therapist’s approach is a good fit for me. There was something missing in the session today. OverallI I Overall, today’s session was right for me. Institute for the Study of Therapeutic Change © 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnsaon

Graphic Representation of ORS and SRS Results ASIST for Agencies 3.51, David Elliott. Available for purchase at

CDOI Tools: ORS and outcomes Here is what we know from the research:  Clients who begin to experience positive change early in treatment are very likely to end treatment on a positive basis  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 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:  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  CDOI provides:  a simple means of improving the value of our clinical work to our clients  a simple means of improving clinicians' effectiveness  a simple means of improving and demonstrating the value of our clinical work to payers of therapy services  A simple means of increasing therapists’ autonomy, accountability, and credibility  A simple means of potentially and significantly reducing necessary clinical documentation

Value of CDOI  Right now, “accountability” is monitored, and therapists and health information professionals are inundated with, extensive paperwork, oversight, and regulatory measures  Clinicians writing that their client is getting better is not likely to change this  Client testimonials that our work is great is not likely to change this  Hard data/evidence that therapy works and has value is likely to change this

Value of CDOI  What payers want:  Demonstrated return on their investment  Value for their dollar  Accountability Their stake is in the outcome of the service for which they are paying  If payers have data demonstrating outcome, they have little need for diagnoses, treatment approach used, or extensive documentation to review

Value of CDOI  What stakeholders and regulatory agencies want:  Demonstrated benefit to the clients  Evidence that clients’ welfare and rights are protected Their stake is in consumer protection and satisfaction with services  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  What clients want:  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  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  What therapists want:  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 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. Payers win because they have documented return on their investment Stakeholders/regulators win because CDOI embraces their values 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