Monitoring in family therapy How to stay loyal to our dialogical values? Karine Van Tricht, Peter Rober & Rolf Sundet 2nd 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 Sundet Leuven, 2013 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 Money o Results o Social benefit Psychotherapy o Evidence based o Effective o Efficient ‘To measure is to know’ atmosphere Quality Control Systems

From Evidence Based Practice to Practice Based Evidence RCT’s & Psychotherapy o Specificity & complexity o Generalizability? o External validity? o Creativity? RCT’s & Family Therapy = trouble in paradise o What is the diagnosis? o Complexity and specificity of treatment o Who/what is responsible for change?

Monitoring: bridging the gap between research and practice Terminology o Outcome management o Routine Outcome Monitoring o Routine Outcome Measurement o Feedback Oriented therapy o Client Directed Outcome Informed Therapy o Tracking o Monitoring o ROMMEN o QITTEN

Evidence Outcome improvement o Duncan & Sparks, 2009; 2010 o Reese et al., 2010 o Anker, Duncan & Sparks, 2009 o Duncan & Miller, 2000 Drop-out prevention & better dose/effect ratio o Lambert, 2007; 2010 Experienced as useful and helpful o Anker et al., 2011 Leading to a better working alliance o Sundet 2010; 2011; 2012

Monitoring as a way of working together Dialogical space / Culture of feedback Creating Feedback Integrating feedback New way of understan ding Go with the flow Van Tricht & Rober

Monitoring as a therapeutic methodology Our conceptualization o Session by session gathering of feedback by systematically and repeatedly assessing outcome and process variables o Immediate delivery of this feedback to the therapist(s) o Using this feedback to facilitate or improve this specific psychotherapy with these specific clients and these specific therapists o Using this feedback to enrich our insight in the working mechanisms of family therapy Creation of a feedback culture Session by session gathering Feedback delivery Feedback driven Growing insight

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 Client System Therapist System Sources of inspiration (1) Van Tricht, Van den Broeck, Rober, 2011; Rober 2012

Sources of inspiration (2) QIT online (Quality Improvement in Therapy) Stinckens, Smits, Rober & Claes, 2012 Basic PrinciplesCharacteristicsInstruments Practice basedMultidimensionalPsychometrics Process orientedMultimodalA-theoretical Feedback drivenFlexibelChange sensitive Broad spectrumInternetbasedClinically relevant User friendly Easily 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 conclusion The 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 To focus To structure To explore To tell and express To visualizeTo 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

Conceptual Framework QIT Family Van Tricht & Rober

Specificity of integrating monitoring in Family Therapy Instrumental level o Adult & child versions o Outcome & process Implementational level o Clear introduction o In session: Apart / together o Home work: Apart / together o On paper or electronic Dialogical level o Open, curious, interested and non-judgmental T attitude o Feedbackloops: how, what, when o 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 outcome o 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 therapist o Relational (im)balances split alliances/siding/moving toward equilibrium Muran & Barber, 2010

“An emerging quality of collaboration in relation to the necessary accomplishments, arising from a web of interacting relational dynamics” Muran & Barber, 2010

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

Publications Sundet, 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), Sundet, R. (2011). Collaboration: Family and therapists perspectives of helpful therapy. Journal of Marital and Family Therapy, 37(2), Sundet, R. (2012). Therapist perspectives on the use of feedback on process and outcome: Patient focused research in practice. Canadian Psychology, 53(2), 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).