1. Is this an unrealized potential to inform practice?
Without question it is an unrealized potential, although more and more people are getting on board all the time. When you consider that outcome informed practice improves outcomes more than anything in our field since its inception (sounds like hyperbole but it isn’t), it is really a wonder that everyone isn’t doing it. But many are. The outcome system of the Heart and Soul of Change Project or the Partners for Change Outcome Management System (PCOMS) is recognized by two states (Arizona and Colorado) as an evidence based treatment and it 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. Norway is currently implementing nationally in their family counselling offices. Given that now 9 RCTs (Lamberts and ours) demonstrate the significant advantages of outcome informed practice, I think it is only a matter of time until it is considered standard practice.

2. Why, given all the time, money, and other resources dedicated to assessing outcomes in behavioral health, is there not a widespread adoption and implementation of outcome measurement?
There are a few reasons. First it hasn’t been a part of the vernacular of our field at the clinician level. For anyone in the field for a few years, it is a totally foreign concept and most folks assume the best regarding effectiveness. It is critical that graduate education step up to plate here and groom a new generation of mental health/substance abuse professionals that are savvy about outcome informed practice. Second, the field has not provided clinicians with any feasible, clinician friendly way to manage outcomes until recently. Some have been turned off by cumbersome and lengthy measures designed by researchers that don’t appear to be related to the day-to-day work of the front line therapist. Finally, many are afraid because of all the talk about P4P and other ideas that suggest that some will be punished who do not measure up to some arbitrary standard. The whole process of outcome measurement and management need to makes sense to front line therapists and appeal to their nearly universal desire to do good work and get better over the course of their careers. That is why the implementation process of the Project emphasizes both a top down and bottom process. It includes attention to things that makes sense to therapists: 1) common factors; 2) a nuanced clinical process; 3) and therapist development.

The common factors, those elements of psychotherapy running across all models that account for change (Duncan, 2010; Duncan et al., 2010), provide an overarching framework for the PCOMS intervention. Integrating the use of PCOMS within the larger literature about what works in therapy promotes therapist understanding of the feedback process and adherence to the feedback protocol. PCOMS is presented as the tie that binds these healing components together, allowing the factors to be expressed one client at a time. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitoring of outcome, heightens hope for improvement, fits client preferences, maximizes chances for a strong alliance, and is itself a core feature of therapeutic change (Duncan, 2010).

Although the over 300,000 administrations of the measures has yielded invaluable information regarding the psychometrics of the measures, trajectories, algorithms, etc., PCOMS remains a clinical intervention embedded in the complex interpersonal process called psychotherapy. For successful implementation and ongoing adherence, PCOMS must appeal to therapists at a clinical level in ways that the numbers or data or even the research never can. Consequently, PCOMS is described as the clinical process that it is—one that requires skill and nuance to achieve the maximum feedback effect. PCOMS speaks to therapists “where they live” by providing a methodology to address those clients who do not benefit from their services.

Similarly, a focus on therapist development provides a positive motivation for therapists to invest time and energy in PCOMS. There will always be organizational motivations for PCOMS in terms of improved outcomes and reduced costs–the language of “return on investment” and “proof of value.” But there is also the personal motivation of the therapist, the very reason most got into this business in the first place: to make a difference in the lives of those served. The groundbreaking research by Orlinsky and Rønnestad (2005) about therapist development (now over 11,000 therapists included) demonstrates that nearly all therapists want to continue to improve throughout their careers and harnessing this motivation is part and parcel to successful implementation. PCOMS appeals to the best of therapist intentions and encourages therapists to collect ORS data so that they can track their development and implement strategies to improve their effectiveness (Duncan, 2010).

Including these larger themes allows therapists to see that the intentions of PCOMS go well beyond management or funder’s cost or efficiency objectives—client based outcome feedback is about client privilege and benefit, and helping therapists get better at what they do. In addition, it is also critical that therapists know that management only intends to use data to improve the quality of care that clients receive, that there will be no punitive use of the data in any way, shape, or form. Given that most therapists improve their outcomes with feedback ( 9 of 10 therapists improved in the Anker et al. trial), a positive, non-competitive approach goes a long way to assuage therapists’ fears.

3. We go to the doctor and expect that our blood pressure will be taken, we will be weighed, and our heart rate monitored. But when we go see a behavioral health professional there is no such standard measures. Is this patient preference? Clinician Preference? Both?
It is definitely not client preference. Consumers want to be involved in their own care. However, they don’t want to do meaningless paperwork that takes away from their time with the therapist. Consumer involvement in all decisions that affect care is the foundation of the PCOMS intervention, including persons not of the dominant culture as well as the traditionally disenfranchised. We have found that when people understand the purpose of the measures (keeping their voice central and making sure they are getting what they want), refusal rates are about one in a hundred. This is far more of an issue for therapists as discussed above.

4. Where do you see the field going in the near term?
Given that there are now nine RCTs supporting it, the time for client-based outcome feedback seems to have arrived (Lambert, 2010). I think that within 5 years, it will be standard practice. My optimism comes from several recent events. For example, the American Psychological Association (APA) Presidential Task Force (hereafter Task Force) on Evidence-Based Practice in Psychology (EBPP) defined EBPP as “the integration of the best available research with clinical expertise in the context of patient (sic) characteristics, culture, and preferences” (Task Force 2006, p. 273). Two parts of this definition draw attention to client feedback and to tailoring services to the individual client. First, regarding clinical expertise, the Task Force submitted:
Clinical expertise also entails the monitoring of patient progress… If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate. (APA, 2006, p. 276-277)

And second, “in the context of patient characteristics, culture, and preferences,” emphasizes what the client brings to the therapeutic stage as well as the acceptability of any intervention to the client’s expectations. The Task Force said:
The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential (Task Force, 2006, p. 280).
Outcome, in other words, is not guaranteed regardless of evidentiary support of a given technique or the expertise of the therapist. Client-based outcome feedback must become routine.

Further support comes from APA’s Division 29 Task Force on Empirically Supported Relationships who advised practitioners “…to routinely monitor patients’ responses to the therapy relationship and ongoing treatment. Such monitoring leads to increased opportunities to repair alliance ruptures, to improve the relationship, and to avoid premature termination” (Ackerman et al., 2001, p. 496). Finally, two other recent endorsements of outcome management by APA have emerged. First the APA Commission on Accreditation (2011) states that students and interns: “Be provided with supervised experience in collecting quantitative outcome data on the psychological services they provide…”(2011, C-24). And second, APA recently created a new outcome measurement database to encourage practitioners to select outcome measures for practice ((http://practiceoutcomes.apa.org).

So change is on the horizon.

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Consider the reach of CDOI/PCOMS: 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. I think it is safe to say that CDOI and PCOMS are becoming a part of the vernacular of providing mental health and substance abuse services.

The Norwegian-American research team (Jesse Owen, Morten Anker, Jacqueline Sparks and Barry Duncan) has scored again, our fourth article based on the massive Norway Couple Feedback Study. Our article, “Initial Relationship Goal and Couple Therapy Outcomes at Post and Six Month Follow Up” has been accepted for publication in the Journal of Family Psychology. This study shows the benefits of knowing what couples want to accomplish in therapy at the outset as well as how couple therapy can help folks regardless of their goals of wanting to improve the relationship or get out of it. It is based on the scale developed by Morten Anker as well as his experience with couples wanting a variety of different things from therapy. Most if not all research in couple therapy deals with couples who desire to improve their relationship but that only covers a portion of the couples we see in real life. This study addresses that reality. It confirms the common sense notion that couples wanting to improve their relationship get better outcomes and are more likely to be together at follow up than couples in which one or both individuals are seeking clarification regarding the viability of the relationship. Moreover, it also demonstrates that couple therapy can benefit clients regardless of their initial goal. We conclude that therapist awareness of each individual’s relationship goal prior to couple therapy could enhance outcomes and treatment tailored according to initial goals could set the stage for positive outcomes however defined.

Jesse Owen, who is now a Project Leader, is doing a webinar via the member site on January 27 about these issues (Become a CDOI Member to participate):

The Couple Therapy that Nobody Talks About: Ambivalence, Commitment, and Change
This webinar discusses couple therapy in which at least one partner is ambivalent about the viability of the relationship. Commitment is vital for couples to successfully develop a secure emotional base and maintain a healthy relationship. When commitment wavers it affects nearly all aspects of the relationship, such as communication, couple identity, willingness to sacrifice, as well as respect, trust, and safety. Treating couples with wavering commitment is rarely discussed in either the theoretical or empirical literature. This webinar covers: (a) cutting-edge research on the importance of assessing couples’ initial relationship goals as a facet of the working alliance; (b) a theoretical framework to understand couples’ commitment; and (c) treatment guidelines for treating couples when at least one partner desires to clarify the viability relationship.

Two other items of interest: A brief video about On Becoming a Better Therapist that I did at APA: http://www.apa.org/pubs/books/interviews/4317217-duncan.aspx

And an interview I did with an old friend from graduate school who hosts a radio show:
http://www.clientdirectedoutcomeinformed.com/media/mp3/Wake_Up_Call_2011-11-20.mp3

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There are five features of implementation of client directed, outcome informed (CDOI) clinical work and the Partners for Change Outcome Management System (PCOMS) that distinguish the Heart and Soul of Change Project:

1. Attention to the common factors of change and the evidence demonstrating that most of therapist variability is accounted for by alliance abilities: PCOMS, the feedback intervention, is viewed as an interconnected part of the healing factors of psychotherapeutic intervention and the tie that binds the other factors together allowing the factors to be expressed one client at a time. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitoring of outcome, heightens hope for improvement, fits client preferences, maximizes therapist-client fit and client participation, and is itself a core feature of therapeutic change. The natural fit between the common factors research literature and PCOMS is integral to the implementation process of the Heart and Soul of Change Project.

2. A focus on the clinical nuances of using PCOMS as detailed in On Becoming a Better Therapist, addressing how to get the maximum feedback effect. Although the now 300,000 administrations of the measures and all the information that has yielded in terms of the psychometrics of the measures, trajectories, algorithms, etc., has been invaluable, PCOMS remains a clinical intervention embedded in the complex interpersonal process we call psychotherapy. The Heart and Soul of Change Project keeps this in mind and therefore appeals to the clinician in ways the numbers never can.

3. Similarly, a focus on therapist development and how therapists naturally want to get better over the course of their careers provides a positive motivation for therapists to invest time and energy in PCOMS. There will always be organizational motivations for PCOMS in terms of improved outcome and reduced costs–the language of “return on investment” and “proof of value.” But there is also the personal motivation of the therapist, the very reason most of us got into this business in the first place: to make a difference in the lives of those we serve. Research demonstrates that nearly all therapists want to continue to improve over their careers and harnessing this motivation is part and parcel of how the Heart and Soul of Change Project implements PCOMS.

4. Attention to Multiculturalism and Social Justice is a key element of PCOMS (and of the Training of Trainers Conference). Client privilege and voice form the foundation of the PCOMS intervention. Privileging the client via PCOMS levels the counseling process by inviting collaborative decision making, honoring client diversity with multiple language availability, valuing local cultural and contextual knowledge, and amplifying the voice of the disenfranchised. We see PCOMS as a way of building cultural proficiency.

5. Attention to the concept of “Recovery” as defined by the National Consensus Statement is core to PCOMS and a natural fit—a journey best directed by the individual in the context of a true partnership providing both hope and accountability. PCOMS offers a vital way to operationalize the Consensus Statement into clinical practice.

The Training of Trainers event is coming up quick.  Learn how to train others in CDOI and PCOMS! Escape the cold this winter and attend the Training of Trainers Conference in sunny Florida, January 30-February 3.

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I just returned a few weeks ago from Europe which included training in The Netherlands, Switzerland, and Belgium which I did for Korzybski International. They run an extensive multiyear post graduate training program in Solution Focused Cognitive Therapy, which in Europe is called the Bruges Model as well as many other useful therapeutic ideas and practices. This was my second trip for them and the more I get to know them the more I have come to like what they are doing. This trip cemented my involvement in their training program and now CDOI and PCOMS will be a fixed feature of their training. There is now a formal affiliation between the Korzybski Institute and the Heart and Soul of Change Project. This is important because it will help spread the word to many who would have otherwise never heard of CDOI or PCOMS because of language differences. While many Europeans speak English, many do not as well. French speaking folks, for example, have had little exposure to the ideas (the first edition of Heroic Client was translated but it did not include the ORS/SRS) but no longer. There is a translation of the Heart and Soul of Change in the works and I am hopeful that On Becoming a Better Therapist will be next. And, I will be conducting training in France next year which hopefully inspire interest as well.

I am pleased to announce that Luc Isebaert will join The Heart and Soul of Change Project as a Project Leader. I don’t know if you have seen the Dos Equis commercials about the “most interesting man in the world” but since meeting Luc, I beg to differ. Luc is truly a renaissance man, and a walking encyclopedia of art, music, wine, beer (his family ran a brewery and if you know anything about Belgium, you know that beer is a national treasure), history, and of course psychotherapy. Luc is also a gourmet chef and I had an amazing dinner at his home and his partner Sophie (a concert pianist who played for us over a glass of incredible Riesling wine on a piano that Franz Liszt played at the Paris World Fair in 1878). Luc and I share a common heritage in Ericksonian and systemic thinking (hence the name, Korzybski Institute) as well as many perspectives of therapy and training therapists. He co-founded the Korzybski Institute in 1982. His previous position was Chief of the Dept of Psychiatry and Psychosomatics at St John’s Hospital in Bruges. Luc was taken by CDOI’s attention to the common factors as well as the importance of monitoring outcomes.

On a more content related note, Jesse Owen just turned me on to a great alliance article: Crits-Christoph, P., Connolly Gibbons, M, , Hamilton, J., Ring-Kurtz, S., Gallop, R. (2011). The dependability of alliance assessments: The alliance-outcome correlation is larger than you think. Journal of Consulting and Clinical Psychology, 79, 267-278. Once again, a very sophisticated study validates the focus of CDOI and PCOMS. 

This study found that session 3 alliance ratings accounted for 4.7% of the variance but the average of sessions 3-9 explained a whopping 14.7% of outcome variance. This study suggests that a single session view of the relationship between the alliance and outcome very likely underestimates its impact on ultimate treatment outcome. Bottom line: Don’t underestimate the power of the alliance! In addition they recommended ongoing alliance assessment with alliance measures that don’t put too much burden on clients but that are reliable and valid. Do you know of any?

Don’t forget the upcoming webinar on supervision (Supervision Matters: Tapping into Therapist Aspirations to Get Better) coming up this Thursday, June 30 at noon Central. Join the CDOI member site to catch this one and many others.

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As I have said before, the reason that we are called the Heart and Soul of Change Project is because we are committed to both creating and disseminating research from naturalistic sites that operationalize our mission to privilege the client’s voice and enter true partnerships with those we serve. That is our ongoing project. Besides the ones I mentioned in the “Bob Bohankse Land” blog, there is another project well underway in one site and beginning in another and a completed one that just made the light of day in the Journal of Family Psychotherapy. The first randomized clinical trial of feedback ever done with children and adolescents in the schools (or anywhere else) has been underway for some time in Mary Haynes Land, otherwise known as Maine and Community Health and Counseling Services. This project has been a collaborative effort of Mary Haynes (who is also a Project Leader of the HSCP) and Liam Shaw, a supervisor of the Skowhegan office (and several dedicated therapists) with the ongoing support of Executive Director Dale Hamilton. Another site has just signed on, thanks to the leadership of Bob Bohanske and the support of the President of Southwest Behavioral Health, Jeff Jorde. Also part of the Phoenix team are Vice President Ed McClelland and Clinical Supervisor Alysson Zatarga, who will really be the ones making it happen. This study could really make a difference in how services are delivered in the schools, ensuring that kids and adolescents have a voice in decisions about their care. This study is an collaborative of Barry, Project Leader and UCA Professor John Murphy, and Art Gillaspy, Associate Professor at UCA. Considering the impact the Norway Couple Feedback Trial had on how couple services are delivered in Norway, this study could change the way services are provided in the schools.

And the completed and published project: Anker, M., Sparks, J., Duncan, B., & Stapnes, A. (2011). Footprints of couple therapy: Client reflections at follow up using a mixed method design in routine care. Journal of Family Psychotherapy, 22, 22-45. In this study, we explored client experiences of couple therapy using their written responses to questions at 6-month follow-up. We did a qualitative thematic analysis and a number of themes emerged along with client evaluations of those themes. We analyzed these with respect to the overall sample, gender, and the feedback/no-feedback groups in the original Norway Feedback Trial (Anker, Duncan, & Sparks, 2009). There were two general domains—relationship and tasks, that neatly fit Bordin’s definition of the alliance. Respondents were generally satisfied with the relationship domain, but there were more dissatisfied responses in the tasks domain. Basically, clients indicated that they liked therapists who were friendly, warm, and able to be neutral. There were more negative assessments of therapists not giving enough concrete suggestions, not challenging when appropriate, or not structuring the session. These findings did not differ significantly by gender and supported other the findings from similar studies. What was interesting had to do with the category “service delivery.” This category had the most statements in the tasks domain and there were more negative than positive. Clients were not happy with how the scheduling of therapy happened, the frequency of meetings, and lack of therapist follow-through on contacting clients between sessions and being flexible about scheduling. This was very interesting as this element of our work is rarely discussed in the literature, or training for that matter. But it is an important aspect of the alliance. Even more interesting, this was the one category that differed between the feedback and no-feedback groups, with no-feedback clients more dissatisfied with service delivery. We weren’t exactly sure what this meant, but speculated that therapists routinely getting and responding to feedback somehow were more attentive to their clients in these areas. We also asked couples what they thought of the feedback process. Over 60% of clients found it useful while less than 30% didn’t find it helpful. But the client’s goal for the relationship was important here. Of those clients who indicated that his or her goal was to improve the relationship, over 80% found the feedback process helpful.

Here is the article:

Finally, don’t forget this month’s webinar: Tuesday, May 31 at Noon Central: George Braucht and Neil Kaltenecker present: “Stand by Me: Recovery-Oriented, Person-Directed & Outcome Informed Peer Services”

This webinar highlights an application of CDOI skills and tools that blend the alcohol and other drug use recovery-oriented (RO) systems of care model with person (instead of client)-directed (PD) and outcome-informed (OI) peer-delivered services. As empirically demonstrated, transforming acute care models and techniques into CDOI services achieves improved efficiencies and outcomes that can contribute significantly to reaching the enhanced service goals fostered by the Parity and Affordable Healthcare laws. A key takeaway of this webinar is an example of how to integrate into existing services the experience, strength and hope of ROPDOI-trained people in long-term recovery along with the pervasive, culturally-diverse community resources for initiating and sustaining recovery. Building on Georgia’s seminal work on mental health peer specialists, the webinar focuses on the service delivery tools used by peer recovery coaches who have completed the Certified Addiction Recovery Empowerment Specialist (CARES) Academy. This webinar is suitable for behavioral, healthcare and social service providers and administrators; recovery community members; and others who are seeking or in long-term recovery. Participants who have not already seen Dr. Bob Bohanske’s webinar Operationalizing recovery: The Consensus Statement in Action are encouraged to view it before this webinar.

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I usually don’t write on this blog about the places I visit to do training because I don’t really want the blog to be a twitter accounting of my travels to exotic and not so exotic places. But I have to talk about my travels this week to Bob Bohankse land, otherwise known as Phoenix, Arizona. I conducted a two-day training: one day was an overview of CDOI for the new folks and the second day covered the clinical nuances of getting the max out of the measures and the four steps of CDOI supervision for the seasoned staff members and supervisors. But I went a day early and stayed an extra day so Bob and I could work on and prioritize the many projects (that is the reason that we are called the Heart and Soul of Change Project because we are committed to doing things to both create and disseminate research from naturalistic sites that operationalize our mission to privilege the client’s voice) that would advance the state of knowledge about CDOI and PCOMS and therefore further help to spread the word. Although there are several, two in particular deserve special mention. First is an article to discuss the incredible data that Bob’s agency, Southwest Behavioral Health has collected. Bob has data on over 6000 clients and the results are nothing short of phenomenal, both for kids and adults. As a teaser, here is a piece of the data offering a comparison to services delivered without CDOI and PCOMS:

Children with CDOI: Achieved reliable change on average (including caretakers) and 47% achieved all goals (v. 32%) in 128 less days.
Adults with CDOI: Achieved reliable change on average and 33% achieved all goals (v. 19%) in 138 less days.

The article also proposes that that CDOI and PCOMS not only offer a way to improve outcomes while increasing productivity and saving money, it also operationalizes the vision of “recovery” as described by the SAMSHA and the Consensus Statement of Recovery. Bob will be presenting a webinar about Operationalizing Recovery and his data on April 22. Sign up for the members site now!

The second project is joint project of Southwest Behavioral Health, the Erikson Foundation, and the Heart and Soul of Change Project, and it is redo of the “Impossible” Case Project I did way back in the early to middle 90’s that culminated in the book Psychotherapy with “Impossible” Clients. This was an inspiring project that really changed the way that I did psychotherapy. I am very proud of that project and what we found but I really didn’t know what I was doing, research wise. There were no quantitative findings and no systematic assessment of outcome or of the chart review process. Further, although I conducted interviews with all the clients at termination, it was not a systematic qualitative inquiry and therefore didn’t mine all the golden data that was there. But this project will. It will repeat the study of clients who have had multiple treatment failures and pursue their experience and perceptions of why those failures occurred as well as why the current round produced a different outcome (hopefully). The project will include Bob, me, and Jacqueline Sparks (our qualitative consultant), as well as Lynette Small and Heath Kilgore (Southwest Behavioral folks).

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). Consequently we are not just interested in capitalizing on what others do; rather the HSCP team produces research and directly translates it to clinical practice in the real world. The Norway Feedback Trial and Alliance Study is a case in point–these studies led to national implementation of PCOMS in Norway. And the hits just keep coming. First, the third randomized clinical trial (RCT) demonstrating the dramatic improvement in outcomes provided by merely adding feedback to therapeutic mix via the ORS and SRS is now in print. This is the replication study of the Norway Feedback Trial and it is an uncanny replication. This study found almost identical findings: four times as many couples achieved clinically significant change and the effect size for feedback was .49. Congratulations to Jeff Reese, Project Leader of the HSCP, and his research team for helping put CDOI and PCOMS on the map. This study culminated in our submission to SAMSHA for evidenced based treatment status (more on that later as well as the important distinction between evidence based treatment and evidence based practice).
Here is the study:

We have three RCTs in progress: one with returning veterans, one with kids in the schools, and one study seeking to ferret out what really causes the feedback effect, or what is called a component study. Stay tuned.

Next in print is the “Footprints” article to appear next month the in Journal of Family Psychotherapy. This article looked at 6 month follow up data from the Norway Feedback Trial. As just a teaser of a study that reaffirms the importance of the alliance plus throws in a few curves, we found that clients in the non-feedback group were significantly more likely to complain about the therapy service delivery than feedback clients. More on this next month.

And a soon to be published (in the 2nd edition of the John Norcross book, Psychotherapy Relationships that Work) meta-analysis of PCOMS studies conducted by feedback pioneer Michael Lambert and K. Shimokawa found that those in feedback group had 3.5 higher odds of experiencing reliable change and less than half the odds of experiencing deterioration.

Finally, check out the next webinar by Dr. Mary Haynes: Creative Applications: CDOI in Case Managment
This workshop explores the ground-breaking expansion of the use of feedback to case management services. Based on her eight years of experience in extending the use of outcome management to settings other than traditional therapy, Mary will address the unique benefits and challenges of incorporating client feedback in community-based work with adults.

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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/