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?”

Practice based evidence, or the systematic collection of client based outcome feedback, will likely become the rage of the next decade—and for good reason: Feedback pioneer Michael Lambert in his chapter in the just published second edition of the Heart and Soul of Change (2010) reports that effect sizes (ES; a statistical measurement of change) for the difference between feedback and TAU ranges from .34 to .92, unusually large considering that the estimates of the ES of the difference between empirically supported and comparison treatments are about .20. Putting this in perspective, feedback has two to four times the impact of model differences.

Where did this great idea of feedback come from? Howard, Moras, Brill, Matinovich, and Lutz (1996) were the first to advocate for the systematic evaluation of client response to treatment during the course of therapy. When this occurs—when client feedback is systematically collected and used to tailor treatment—good things happen.

For example, using the Outcome Questionnaire 45.2, Michael Lambert really brought this great idea to fruition. He has conducted five RCTs and all five demonstrated significant gains for feedback groups over treatment as usual (TAU) for clients at-risk for a negative outcome. Twenty two percent of TAU at-risk cases reached reliable improvement and clinically significant change compared with 33% for feedback to therapist groups, 39% for feedback to therapists and clients, and 45% when feedback was supplemented with support tools such as measures of the alliance. The addition of client feedback alone, without new techniques or models of treatment and leaving therapists to practice as they saw fit, enabled over two times the amount of at- risk clients to benefit from psychotherapy. Think of the advantage this brings to clinical practice. Systematic feedback allows good outcomes with many of those clients who would otherwise not benefit. 

I am very happy to announce that Michael Lambert, the person most responsible for bringing the power of client feedback to the forefront, will be conducting the next webinar to set the stage for his Heart and Soul of Change conference presentations:

“Yes, It Is Time for Clinicians to Track Outcomes”

Wednesday, January 27, noon to 1:00 Central

Join the person most responsible for the greatest innovation in clinical effectiveness since the beginning of psychotherapy. Register now by joining the CDOI membersite, now over a $400 value for a one year $120 subscription at http://www.cdoimembers.com/

Michael Lambert also inspired our client feedback process, The Partners for Change Outcome Management System’s (PCOMS). PCOMS appeal rests on the brevity of the measures and therefore its feasibility for everyday use in the demanding schedules of front-line clinicians. PCOMS was based on Lambert’s continuous assessment model using the Outcome Questionnaire 45.2, but there are differences beyond the measures. First, PCOMS is integrated into the ongoing psychotherapy process and routinely includes a transparent discussion of the feedback with the client (The Heroic Client). Session by session interaction is focused by client feedback about the benefits or lack thereof of psychotherapy. Second, PCOMS assesses the therapeutic alliance every session and includes a discussion of any potential problems. Lambert’s system includes alliance assessment only when there is a lack of progress. 

Three studies have demonstrated the benefits of client feedback with the ORS and SRS. Miller, Duncan, Brown, Sorrell, and Chalk (2006) explored the impact of feedback in a large culturally diverse sample utilizing a telephonic employee assistance program (EAP). Although the study’s quasi-experimental design qualifies the results, the use of outcome feedback doubled overall effectiveness and significantly increased retention. Two recent RCTs used PCOMS to investigate the effects of feedback versus TAU. First, in an independent investigation, Reese, Norsworthy, & Rowlands (2009) found that clients who attended therapy at a university counseling center or a graduate training clinic demonstrated significant treatment gains for feedback when compared to TAU. Finally, our recent study in Norway (Anker, Duncan, & Sparks, 2009), the largest RCT of couple therapy ever done, found that feedback clients reached clinically significant change nearly four times more than non-feedback couples. The feedback condition maintained its advantage at 6 month follow-up and achieved nearly a 50% lower separation/divorce rate.

A fourth study, a replication of the Norway Feedback Study by Jeff Reese has been submitted and a fifth study addressing feedback in an acute inpatient unit is about to get underway.

Read more on the resources page at http://heartandsoulofchange.com/resources/