The Heart and Soul of Change Project (HSCP) is a practice-driven, training and research initiative that focuses on what works in therapy, and more importantly, how to deliver it on the front lines via client based outcome feedback, or what is called the Partners for Change Outcome Management System (PCOMS: see below). Embracing the values of social justice and an expectation that recovery is possible for everyone, HSCP is about making you better at what you do for the very reason you became a helper to begin with—to make a meaningful difference in as many lives as possible. The strength of what the client brings to the change process and the impact of the alliance inspired Barry Duncan, the director of HSCP to name the popular book about the common factors as well as this Project—the client is the Heart and the alliance is the Soul of therapeutic transformation. Systematic feedback allows both to be empowered for maximum client benefit. The Project features an international community (see the Project Leaders) of helpers of all stripes and flavors as well as researchers and professors, all dedicated to privileging clients and making us better at what we do. The HSCP will also focus on therapist development, not only making us all better at what we do but also encouraging helpers to attend to their professional growth so that they remain a vibrant influence in client lives. The Project provides the portal for entry into the Heroicagency List, where over 800 professionals from all corners of the globe participate in advancing the cause of forming true partnerships with clients, inviting them into the inner circle of decisions about their care.  Join now!

Our Mission
Our mission is to disseminate client directed, outcome informed (CDOI) ideas and practices to those on the front-lines, and to promote research and education to transform mental health services to include consumers as full partners.  Find more information about CDOI at http://heartandsoulofchange.com/training/cdoi-members/what-is-cdoi/

What is PCOMS?
PCOMS stands for Partners for Change Outcome Management System. Devoted to empirically-derived clinical practices, PCOMS incorporates the most robust predictors of therapeutic success into an outcome management system that partners with clients while honoring the daily pressures of front-line clinicians. Unlike other methods of measuring outcome, this system truly gives clients the voice they deserve and assigns consumers key roles in determining how services are both delivered and funded. It is the only system that includes a transparent discussion of the results with clients and the only system to include routine measurement of the therapeutic alliance. PCOMS was launched by Barry Duncan and Scott Miller after 7 years of development, research, and publications in peer reviewed journals to establish the psychometric validation of its instruments. Since that time, PCOMS has been shown in 3 randomized clinical trials to significantly improve effectiveness in real clinical settings.

PCOMS and/or CDOI are recognized by two states (Arizona and Colorado) as an evidence based treatment and PCOMS is currently under review by SAMHSA for national evidence based treatment designation. PCOMS has been implemented by hundreds of organizations, public and private, by thousands of behavioral healthcare professionals in all 50 states and 20 countries serving over 100,000 clients a year. National implementation by the Health Directorate for Children, Youth, and Families of Norway is currently underway. 

PCOMS uses two brief scales, the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS) to measure the client’s perspective benefit and the alliance, respectively. The ORS is a four item visual analogue scale that measures psychological functioning and distress. It is a self report instrument designed to measure client progress repeatedly (at the beginning of each session) throughout the course of therapy. The ORS reflects key areas of client functioning: individually (personal well-being), interpersonally (family, couple, close relationships), socially (work, school, friendships), and overall (general sense of well-being). Clients put a mark on the line of each item nearest the pole that best describes their experience, and therapists score each 10-centimeter line using a centimeter ruler (each item is assigned a score ranging from 0 to 10). The scores are totaled, ranging from 0 to 40, with lower scores reflecting more distress

The client’s perspective of the alliance with the therapist is measured with the SRS.  The SRS is also a four-item visual analog scale and is based on Bordin’s (1979) classic delineation of the components of the alliance: the relational bond and the degree of agreement between the client and therapist about the goals and tasks of therapy. Clients place a mark on a 10-cm line nearest the pole that best describes their felt experience with their therapist. Specifically, the instructions of the SRS direct clients to rate their therapist on the following items: relationship with the therapist (“I felt heard, understood, and respected”), goals and topics (“We worked on or talked about what I wanted to work on or talk about”), the approach used in therapy (“The therapist’s approach is a good fit for me”), and the overall rating of the session (“Overall, today’s session was right for me”). The client’s marks on the four items are measured with a centimeter ruler and totaled for a score ranging from 0 to 40. ORS and SRS scores are recorded in an Excel file or ASIST or MyOutcomes.com program. Agencies implementing PCOMS receive ongoing consultation and data analyses at all phases of implementation. Implementation is a process that requires ongoing support and feedback.

Administration, Scoring, Interpretation, and data Storing Tool for the ORS and SRS (ASIST) and MyOutcomes.com
The ASIST program and MyOutcomes.com were developed to provide mental health and substance abuse professionals (MHP), administrators, and third party payers with feedback about the client’s response to services, thus enabling the MHP to provide more effective care at a substantial cost reduction. ASIST, available for both individual and agency use,  is a simple program that uses Excel to administer the measures, provide real time feedback regarding the client’s score compared to the target score, and aggregates data to analyze provider and program effectiveness. ASIST provides a low cost method to begin collecting and using data to inform and tailor mental health and substance abuse services. Visit www.clientvoiceinnovations.com for more information. MyOutcomes.com is an interactive, web-based system that not only gives real time feedback and comparison to expected trajectories for change, but also provides empirically-based suggestions, written specifically to clients, for increasing the likelihood of success. MyOutcomes.com enables a wide range of data collection and statistical reporting possibilities unencumbered by the limitations of end user software, and can be interfaced with existing record keeping and data collection systems. For more information, visit www.myoutcomes.com.

The Three Randomized Clinical Trials

Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 693-705.  
Feedback (using PCOMS) v Treatment as Usual RCT, therapists serving as own controls (Peer Reviewed Journal—Journal of Consulting and Clinical Psychology)
N = 410

• The coefficient for feedback was a significant and positive predictor of outcome at posttreatment after controlling for pretreatment functioning. The predicted score of an individual in a couple with a therapist who received feedback was 4.89 points higher on the ORS than one who did not The ES for individuals who received feedback versus those who did not was d =  0.50
• The proportion of clients responding to treatment (achieved reliable or clinically significant change) in the TAU group was 41.7% (both in couple, 22.6%) and in the feedback group was 64.6% (both in couple, 50.5%).
• Significantly fewer at-risk cases emerged in the feedback condition (74.5% in TAU vs. 54.4% in feedback group). The proportion of at-risk couples who responded (both in couple) in the TAU condition was 9.2% and 28.6% for the feedback condition.
• Six month follow-up: The coefficient for feedback remained significant but was somewhat smaller than the pre- to posttreatment effect. The predicted score of an individual with an average ORS score who received feedback was 3.97 points higher on the ORS than one who did not. The ES for individuals from couples who received feedback versus those who did not was d = 0.44.  The proportion of clients responding to treatment as measured by the ORS in the TAU group was 39.1% (both in couple, 18.8%) and in the feedback group was 66.7% (both in couple, 47.6%). A significantly greater proportion of couples were intact (i.e., not divorced or separated) in the feedback condition (81.59%) than in the TAU condition (65.75%).
• Fidelity of implementing the PCOMS was addressed through the provision of weekly checks by the principal onsite investigator. Two simple ways to incorporate and discuss feedback with clients were used. Therapists were given graphs to plot ORS and SRS scores and were also given a table of 50th percentile estimated treatment responses (ETRs) for all possible intake scores (0–40), enabling them to compare their clients’ ongoing scores with the 50th percentile expected change trajectory derived from the ORS database. To ensure that therapists used the table for comparison at least once, therapists were asked to put the expected change score from the second session on the couple’s graph. The primary investigator reviewed charts weekly to ensure this occurred. In addition, on-going training and verbal implementation reminders for the intervention protocol were provided throughout the study.  

Reese, R., Norsworthy, L., & Rowlands, S. (2009). Does a continuous feedback model improve psychotherapy outcomes? Psychotherapy, 46, 418-431. 
Feedback (PCOMS) v. Treatment as Usual RCT (two samples), therapists served as own control in first sample (Peer Reviewed Journal—Psychotherapy)
N = 148 (74 participants in each sample)

• Repeated measures found that clients in the feedback condition demonstrated statistically significant more improvement (12.69 vs. 6.82 points in Study 1; 10.84 vs. 5.04 points in Study 2).  The ES for individuals who received feedback versus those who did not was Study 1 (d = 0.54) and Study 2 (d = 0.49).
• The proportion of clients in each condition responding to treatment (achieved reliable change) in Study 1 was 54.2% (TAU) versus 80.0% (feedback) and 41.4% (TAU) versus 66.67% (feedback) in Study 2.  The differences in reliable change were statistically significant with both samples.
• Fidelity of implementing the PCOMS was addressed through the provision of weekly supervision. On-going training and verbal implementation reminders for the intervention protocol were provided throughout the study.  

Reese, R., Toland, M., Slone, N., & Norsworthy, L. (2010). Effect of client feedback on couple psychotherapy outcomes. Psychotherapy, 47, 616-630.
Feedback (PCOMS) v  Treament as  Usual RCT (Peer Reviewed Journal—Psychotherapy)
N = 92

• The coefficient for feedback was a significant and positive predictor of outcome at posttreatment after controlling for pretreatment functioning. The predicted score of an individual in a couple with a therapist who received feedback was 4.94 points higher on the ORS than one who did not. The ES for individuals who received feedback versus those who did not was d = 0.48.
• The proportion of clients responding to treatment (achieved reliable or clinically significant change) in the TAU group was 31.6% (both in couple, 15.8%) and in the feedback group was 66.3% (both in couple, 44.4%).
• Growth rates between couples receiving TAU vs. feedback during couple therapy were computed using hierarchical linear modeling and found that couples in the feedback condition improved more quickly than couples in the TAU condition.
• Fidelity of implementing the PCOMS was addressed through the provision of weekly supervision. On-going training and verbal implementation reminders for the intervention protocol were provided throughout the study.  

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