I recently did a training in Colorado Springs and was asked by talented young therapist, Andrew Van Dyke to address four questions for the Psych Society newsletter:

1. Do you have any tips on how to motivate resistant clients, i.e., non-compliant, court-ordered, or mandated clients to positive change? Clients may not share our motivations, but they certainly hold strong motivations of their own. Research has now established that the critical process-outcome link in successful therapy is the quality of the client’s participation. Clients who collaborate in therapy, are engaged with the therapist, and involve themselves with a receptive and open mind will likely profit. Owing to the importance of clients’ positive involvement for outcome, their motivation—not only just for being in therapy, but also for achieving their own goals—has to be understood, respected, and actively incorporated into the treatment. To do less or to impose agendas motivated by theoretical prerogatives, personal bias, and perhaps some sense of what would be good for the client, invites “resistance.”What we come to call resistance may sometimes reflect the client’s attempt to salvage a small portion of self-respect.

Important findings regarding court-ordered or mandated clients emerged from Project Match, the largest study of substance abuse ever done. First, there was no difference in outcome between mandated and non-mandated clients; and second, the only predictor of outcome, whether the client was voluntary or involuntary, was the therapeutic alliance. Whether clients are “resistant” or mandated, job one is the therapeutic alliance. It’s not always easy. But you didn’t think that “therapeutic work” business only applied to clients—did you?

2. As students, we often get overwhelmed with a plethora of theoretical models and techniques. How important is technique delivery in being an effective therapist who creates positive results in the majority of our clients? Sometimes our altruistic desire to be helpful hoodwinks us into believing that if we were just smart enough or trained correctly, clients would not remain inured to our best efforts—if we found the Holy Grail, that special model or technique, we could once and for all defeat the psychic dragons that terrorize clients. Amid explanations and remedies aplenty, therapists courageously continue the search for designer explanations and brand name miracles—disconnected from the power for change that resides in the pairing of two unique persons, the application of strategies that resonate with both, and the impact of a quality partnership.

Don’t get me wrong. There is nothing wrong with learning about models and techniques—in fact, it is a good thing because it allows you to fit more client preferences. But becoming beholden to one is folly as is the belief that any model represents the way that people can be helped. Technique is important but it is only effective to the extent that it engages the client in purposeful work. If it does not pass that fundamental test, it has no value regardless of its evidentiary support. Moreover, a particular technique is only important to the client in your office now if it results in measureable benefit. The proof of the pudding is in the eating.

3. What is the history of the use of outcome measures in psychotherapy and what do you think its future role will ultimately be in managed care? Ken Howard first advocated for the evaluation of client response to treatment during the course of therapy, but feedback pioneer Michael Lambert really brought the idea to fruition. He has conducted six RCTs that have demonstrated significant gains for feedback groups over treatment as usual (TAU) for clients at-risk for a negative outcome. The addition of client feedback alone enabled over two times the amount of at- risk clients to benefit from psychotherapy. Our recent RCT of couple therapy found that feedback clients reached clinically significant change nearly four times more than non-feedback couples.

Collecting data and managing outcomes can allow therapists, agencies, and professional organizations to become “players” at the reimbursement table with managed care. The advantages in effectiveness and efficiency that outcome management brings can be bargaining chips that increase the value of our services. We should support managed care systems that collect data and provide immediate feedback about results so that we can adjust quickly to benefit clients. On the other side, we should oppose data collection for the purpose of provider profiling and incentive practices without feedback. Such policies risk killing the spirit of outcome management—to help as many clients as possible—and turning therapists against measuring outcomes.

4. What changes in thinking and practicing are you hoping that participants walk away with from your trainings? There are two things I would love for folks to walk away with. First is that regardless of one’s preferences regarding theory or technique, outcomes can be improved by paying more attention to the heart and soul of change: Rallying the client and his or her resources to the cause, their participation, is the heart of the work; and proactively securing that tried and true but taken for granted old friend, the therapeutic alliance—the soul of change is the alliance. The second change that I hope for is that folks will give client feedback a shot, not some time, not next month or even next week, but with the next client. Client-based feedback substantially increases the effectiveness and efficiency of services—more than anything in the history of our field. It enhances the benefit of any psychotherapy regardless of the model practiced. Nine of ten therapists in our large RCT improved their outcomes with feedback; in fact a therapist in the lowest tier of effectiveness without feedback became the most effective therapist in the study with feedback.

And two announcements: One is that pdfs of all the Heart and Soul of Change Conference presentations are now available at: http://heartandsoulofchange.com/heart-and-soul-of-change-conference-new-orleans-slide-presentations/

And the next webinar is scheduled: our own Bob Bohanske presenting “Implementing CDOI in Public Agencies: Is it Mission Impossible?”

Many exciting things are happening in Norway with CDOI. First I was there to help kick off the Bufetat (Child and Family Services Directorate) pilot implementation of 5 family counseling offices which will begin the nationwide rollout of CDOI (called KOR in Norway) in all 64 agencies across Norway. This massive implementation is in great hands with project leader Marianne Bie, and with the able help of Morten Anker, a Heart and Soul of Change Project (HSCP) Certified Trainer, and Geir Skauli a long time CDOIer. This all began back in 2006 when I did a tour of all the family counseling agencies to introduce CDOI (under the visionary leadership of Berger Hareide and Geir Skauli), but the decision to implement was likely cemented by the Norway Feedback Project. Speaking of the Norway Feedback Project, check out this conversation with principle investigator, Morten Anker.

Get the Norway Feedback Article here: http://heartandsoulofchange.com/resources/articles/

Another very cool thing is what RBUP (Child and Adolescent Psychiatric Services) is doing with CDOI training. Under the leadership of Anne-Grethe Tuseth (the person who brought CDOI to Norway), and with the help of Tor Fjeldstad (another HSCP Certified Trainer), a new training program will soon be launched addressing both academic and clinical training. If you have been following this Blog you know that this is part of the mission of the HSCP, to encourage formal inclusion of CDOI in academic and training programs to promote learning of the ideas and practices early in professional careers. This, in a sense, “institutionalizes” the values of client/consumer privilege and true partnerships via outcome and alliance feedback.

Speaking of academia, I was also privileged to share CDOI ideas as well as their integration with therapist development as presented in my upcoming book On Becoming A Better Therapist to a very esteemed group of faculty/practitioners at the University of Oslo. This was arranged by the famous Norwegian Researcher Helge Rønnestad, who along with David Orlinksy, are the premier researchers investigating therapist development and what it means to be therapist. It was quite a thrill for me to present my integration of these ideas before one of the originators. BTW, Professor Rønnestad called the clinical use of the ORS and SRS “operationalized collaboration,” and noted the likely alliance effects of using the measures the way we do with clients.

And of course, that is why I believe that the Norway Feedback Project and Jeff Reese’s feedback article (to be published in December in Psychotherapy) achieved a positive effect with all clients instead of just those clients at risk, as Lambert’s studies mostly do. I believe the way we clinically use the measures in collaboration with clients makes the difference.

Finally, the Norway Feedback Study also made the Clinician Digest by Garry Cooper in the November edition of the Psychotherapy Networker. Check it out:

http://www.psychotherapynetworker.org/magazine/currentissue/689-clinicians-digest?start=3

Two things continue to excite me about training folks in CDOI: first is the opportunity to meet people on the front lines who truly value this work and strive to get better at it; and two, being able to experience the application of CDOI well beyond its beginnings in traditional outpatient psychotherapy: for example, like Mary Haynes and case management (and other areas), Bob Bohanske and wrap around (and other areas), Barry Winstead and adult inpatient, Dave Claude and residential “co-occurring disorder” services, just to mention a few. Such applications take quite a commitment to client privilege as well as a large dose of creativity to figure out the logistics involved. Any data that can be collected in such settings will go a long way to support CDOI ideas and practices, and further the mission of bringing clients into the inner circle of decision making about their own care. Because before the measures were validated and long before others and our own RCTs found the power of feedback to improve effectiveness, there was a desire to privilege client voice and provide services that are just.

So I wanted to let you know that we are continuing to get more folks on board in such settings. I was in Jackson, Mississippi a couple of weeks ago and they are gearing up for application in child/adolescent inpatient, residential, foster care, and home-based preservation services. Art Ring is leading a very talented group at Mississippi Children’s Home and I look forward to their success. And Wesley Community Action in New Zealand is also taking CDOI to places I never imagined it could go. David Hanna and Robyn Pope are applying CDOI in walk in community centers, services for the elderly who have just transitioned to assisted living arrangements, foster care, and other social services. Their commitment to social justice continues to inspire me. Their credo:

We are working for a just and caring society
We believe positive change is always possible
We work in partnership with people,
We listen actively
We respond with honesty and openness
We remain open to challenge, change and growth
We work …
As members of communities
Out of compassion
As facilitators of positive change

They are starting a network of CDOI interested folks in New Zealand. New Zealanders should contact Robyn at  RPope@wesleyca.org.nz.

On another note, here are my slides for an upcoming workshop in West Palm Beach that provide the rationale for practive based evidence and CDOI.

PBEUpdateSlides