1. www.monash.edu.au Prepared by: Melissa Noonan - Psychologist Department of General Practice Using outcome directed rating scales as a demand management tool for counselling services at Inner South Community Health Service (ISCHS)

2. www.monash.edu.au 2 DHS directions for Counselling Accountability and Effectiveness -Demand management -Evidence-based Practice - Review of Counselling Services in Community Health Discussion Paper - Counselling in Community Health: Future Directions and Guidelines for Quality Counselling

3. www.monash.edu.au 3 Outcome informs practice … client by client Rate of change is monitored and discussed in sessions Frequency of sessions is informed by rate of change Rating of therapeutic alliance is monitored and discussed in sessions Clients for whom outcomes are static or worsening: –May be offered other options - NOT just more of the same! –Are identified and reviewed

4. www.monash.edu.au 4 The Primacy of the Client in Achieving Positive Outcomes The clients subjective experience of change in the early stages of treatment the is one of the best predictors of positive results (Brown, Dreis, & Nace, 1999; Garfield, 1994; Howard, Kopte, Krause, and Orlinsky, 1986; Howard, Moras, Brill, Martinovich, and Lutz, 1996, Lebow, 1997; Smith, Glass, and Miller, 1980; Steenbarger, 1992, 1994; Talmon, 1990) The clients rating of the alliance is the best predictor of engagement and outcome (Duncan, Sparks, & Miller, 2000) Treatment models – including psychodynamic, client centred, alcohol & drug, marriage and family therapy, psychopharmacologic, to psychological interventions have been shown to be equivalent in effectiveness when compared to each other (Duncan, Sparks, & Miller, 2000)

5. www.monash.edu.au 5 Beginnings of the Project A working group of interested counsellors at ISCHS started using the outcome tools with their new clients from late September 2004. The Primary Health Care Research, Evaluation & Development (PHC RED) Fellowship was successfully applied for and commenced in June 2005

6. www.monash.edu.au 6 The Tools: Client outcome and process feedback Outcome Rating Scale (outcome)- ORS –Assesses individual, relational and social functioning –Takes less than a minute to complete and score

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8. 8 The Tools: Client outcome and process feedback Session Rating Scale (process) SRS –Assesses the four components of the therapeutic alliance –Takes less than a minute to complete and score

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11. www.monash.edu.au 11 Sample of Results Chart for ORS scores

12. www.monash.edu.au 12 Interface between to ODW tools and Single Session Therapy (SST Single Session Therapy 30-50% of clients across all treatment models only attend one session Assumptions as to why: –Not pleased with therapy –Resistant But when followed up: –Most didnt return because they had got what they wanted SST seeks to maximise the effect of the first session … as if this is the only session

13. www.monash.edu.au 13 The Aims of the Research To explore the use of ORS and SRS as demand management tools for ISCHS Identify the extent to which clients are achieving positive change in their functioning Identify the extent to which a positive therapeutic relationship is evident in the sample Assess the effectiveness of SST as a demand management tool at ISCHS

14. www.monash.edu.au 14 Method Participants: Recipients of counselling at ISCHS Sample Size: 5 Counsellors. 48 Clients Procedure: Retrospective audit of client files for whom counsellors used outcome tools. Excel spreadsheet designed for this process. Measures: The ORS and SRS and additional variables collated from client files Data analysis: Data analysed using SPSS package

15. www.monash.edu.au 15 Client Demographic Data 34 female 14 male Age range 17- 74 years. Mean age 41yrs Site Consulted - Southport: 35, Prahran 12, St Kilda 1. 31 had completed counselling 17 still in ongoing counselling at time of data collection

16. www.monash.edu.au 16 Results of study Positive change in functioning was measured by a 5 point or more increase in the ORS score from the original score taken to the final score at the end of counselling.

17. www.monash.edu.au 17 Results: Identify the extent to which clients are achieving positive change

18. www.monash.edu.au 18 Results: Identify the extent to which clients are achieving positive change

19. www.monash.edu.au 19 Results: The extent to which a therapeutic relationship is evident SRS Score

20. www.monash.edu.au 20 Results: Analysis of change achieved in Single Session Therapy

21. www.monash.edu.au 21 Where does SST fit? Early results suggest that SST may be considered a useful demand management tool as it demonstrates that positive therapeutic change is occurring very early in the counselling process and delivering a successful result within a very short service period. However to evaluate this in a more rigorous way further research would need to be undertaken.

22. www.monash.edu.au 22 Discussion of Results: Limitations of study Sample size too small to be representative counselling clients at ISCHS Most of the data was gathered by one counsellor at one site Only clients who had completed counselling had scores that could be compared from start to finish

23. www.monash.edu.au 23 Discussion of Results: Interface between SST and ODW Frequently no ORS/SRS administered at SST or FUPC and therefore vital missing data in relation to change. Insufficient support, training, and encouragement for staff to use the measures consistently Lack of adequate information and supervision in relation to scoring and interpretation of the scales

24. www.monash.edu.au 24 What have we learned about the use of the ORS and SRS as demand management tools? ODW offers ways of measuring outcomes and monitoring and reviewing the therapy and the therapeutic relationship. Important for ensuring quality counselling using practice-based evidence Effective in terms of demand management by using client feedback to make timely and prudent decisions about the provision of treatment and when termination of counselling is indicated.

25. www.monash.edu.au 25 Considerations There may be individuals or client groups for whom it is inappropriate to utilise these tools. Awareness of the risk that the tools may be unhelpful in some contexts. Alternative ways of tracking clients functioning where the tools are not utilised need to be examined.

26. www.monash.edu.au 26 Recommendations: Future Research Future research is indicated to be able to more fully evaluate these outcome tools, however preliminary findings are positive in demonstrating their efficacy as part of a demand management strategy. If such a project were undertaken adequate time allocation and funding for the research is vital to its success.

27. www.monash.edu.au 27 Practice Recommendations: Sufficient support, training, and encouragement for staff to use the measures consistently is vital to the effective implementation of these tools at any community based setting Provision of adequate information and supervision in relation to scoring and interpretation of the scales to staff Streamlining processes with the SST model and ODW to reduce complexity and increase its practical application

28. www.monash.edu.au 28 Reflections on the Fellowship: Benefits Extremely beneficial as a clinician to undertake a research project relevant to my work context. Time from usual work allocation to undertake the project Expediential increase in knowledge relating to the theory & use of the measures. Funding for 4 days of training with Scott Miller when he came to Australia Developing research skills and experience

29. www.monash.edu.au 29 Reflections on the Fellowship: Challenges One day a week for 10 months (40 days) was a very ambitious exercise to undertake this type of project Difficult to absorb and process all the aspects involved in undertaking academic level research in a community context Up-skilling using IT: Online Databases, Excel, SPSS, PowerPoint, Endnote. Supervision – inadequate time allocation

30. www.monash.edu.au 30 Acknowledgments The Department of Human Services for project funding Monash University Department of General Practice My Supervisor- Jo Mitchell Pauline Middleton – Hargrave Andrew Library Inner South Community Health The clients Scott Miller and his colleagues at The Institute of Therapeutic Change – www.talkingcure.com