nuancesofthesrs
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MyOutcomes.com sponsored webinar about the nuances of using the Session Rating ScaleTRANSCRIPT
www.heartandsoulofchange.com November, 2012
The Nuances of the Session Rating Scale
Barry Duncan, Barry Duncan, Psy.DPsy.D. www.heartandsoulofchange.com. www.heartandsoulofchange.com561.561.3640 [email protected] [email protected]
www.heartandsoulofchange.com November, 2012
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••Considered most sophisticatedConsidered most sophisticated
TDCRP The Alliance
TDCRP The Alliance
••Considered most sophisticated Considered most sophisticated comparative clinical trial ever:comparative clinical trial ever:
••CBT, IPT, Drug, PlaceboCBT, IPT, Drug, Placebo
•No difference in outcome in outcome ••The The client’s client’s rating of the alliance at rating of the alliance at
Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82.
ggthe second session the best predictor the second session the best predictor of outcome across conditions.of outcome across conditions.
••CBT, 12CBT, 12--step, & Motivational step, & Motivational
Project MATCH The Alliance
Project MATCH The Alliance
,, p,p,InterviewingInterviewing
••NO NO difference difference in outcome in outcome ••The client’s rating of the alliance The client’s rating of the alliance the best predictor of:the best predictor of:
Treatment participation;Treatment participation;D i ki b h i d iD i ki b h i d iDrinking behavior during Drinking behavior during treatment;treatment;Drinking at 12Drinking at 12--month FUmonth FU
Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29.Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK.Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98.
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••600 Adolescents marijuana users:600 Adolescents marijuana users:••Significant coSignificant co morbidity (3morbidity (3 12 problems)12 problems)
The Dodo Also Rules Family The Dodo Also Rules Family WorkWorkCannabis Youth Treatment ProjectCannabis Youth Treatment Project
••Significant coSignificant co--morbidity (3morbidity (3--12 problems).12 problems).
••Two arms (dose, type) and one of Two arms (dose, type) and one of three types of treatment in each arm:three types of treatment in each arm:
••Dose arm: MET+CBT (5 wks), Dose arm: MET+CBT (5 wks), MET+CBT (12 wks), Family Support MET+CBT (12 wks), Family Support Network (12 wks)+MET+CBT;Network (12 wks)+MET+CBT;( ) ;( ) ;••Type arm: MET/CBT (5 wks), ACRT (12 Type arm: MET/CBT (5 wks), ACRT (12 weeks), MDFT (12 wks).weeks), MDFT (12 wks).
No Difference! Approach Approach accounted for 0% of the variance in outcome. accounted for 0% of the variance in outcome. Alliance Alliance predicted: Premature droppredicted: Premature drop--out; Substance abuse out; Substance abuse symptoms symptoms postpost--treatment, and cannabis use at 3 and 6 month followtreatment, and cannabis use at 3 and 6 month follow--up.up.
Helper Variables that Predict Change
Helper Variables that Predict Change
Counselors with theCounselors with theCounselors with the best results:
Are better at the alliance across
Counselors with the best results:
Are better at the alliance across clients; alliance ability accounts for helper differences
clients; alliance ability accounts for helper differences
Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, 75(6), 842-852.; Anker, Owen, Duncan, & Sparks (2010). The alliance in couple therapy. Journal of Consulting and Clinical Psychology, 78(5), 635-645.
www.heartandsoulofchange.com November, 2012
Client/Extratherapeutic Factors (87%)
Feedback Effects15‐31%
ll ffTreatment Effects
13%
Alliance Effects38‐54%
Model/Technique8%
Model/Technique Delivered:Expectancy/AllegianceRationale/Ritual (General Effects)
30‐?%
Helper Effects46‐69%
Relationship FactorsRelationship Factors
The Alliance:
•• Relational Bond Relational Bond •• Agreement on Agreement on goals • Agreement on tasksAgreement on tasks
S Ti th I t fth I t f
38-54%
Duncan, B. (2010). On Becoming a Better Therapist. Washington, DC: APA.
Seven Times the Impact of the Impact of Model/Technique…Accounts Model/Technique…Accounts for Most of for Most of Counselor Counselor VarianceVariance
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The Therapeutic AllianceThe Therapeutic Alliance
Th AlliTh Alli
Means or Means or Methods: Methods: Theory of Theory of ChCh
Goals, Goals, Meaning Meaning
or or PP
The AllianceThe Alliance
ChangeChangePurposePurpose
Client’s View of the Client’s View of the RelationshipRelationship
The Alliance: The Alliance: Over Over 1000 Research FindingsResearch Findings
Quality of the alliance more potent predictor of outcome than orientation, experience, or professional discipline-- recall TDCRP, MATCH, CYT.
Clients rarely report negative reactions before deciding to terminate.
Same holds true for youth and family services
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••Increasingly, the relationship is Increasingly, the relationship is
Research into PracticeThe Alliance
Research into PracticeThe Alliance
g y pg y pviewed as merely “setting the stage” viewed as merely “setting the stage” for the “real” treatment:for the “real” treatment:
••Confronting distorted thoughts;Confronting distorted thoughts;••Recovering forgotten memories;Recovering forgotten memories;••Asking special questions;Asking special questions;••Tapping on or waving fingers in front of the Tapping on or waving fingers in front of the face but the data say:face but the data say:face…but the data say:face…but the data say:
••The alliance deserves far The alliance deserves far more more RESPECT…
Norcross, J. (2010). The Therapeutic Relationship. In B. Duncan et al. (eds.). The Heart and Soul of Change. Washington, D.C.: APA.
Attitude ImportantAlliance is Central Filter
Attitude ImportantAlliance is Central Filter
Is what I am doing and Is what I am doing and saying now building or risking the alliance?
Doesn’t mean you can’t challenge but rather
saying now building or risking the alliance?
Doesn’t mean you can’t challenge but rather that you have to earn the right and, consider the alliance consequences
that you have to earn the right and, consider the alliance consequences
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When the alliance is in trouble…When the alliance is in trouble…
Alliance As An Overarching FrameworkThe Alliance is the Soul
Alliance As An Overarching FrameworkThe Alliance is the Soul
Transcends any beh & is Transcends any beh & is a property of all—from tech. to scheduling appt
Purpose is to engage in purposive work
a property of all—from tech. to scheduling appt
Purpose is to engage in purposive work
Have to earn it each & every time; alliance is our craft; practice elevates to art
Have to earn it each & every time; alliance is our craft; practice elevates to art
www.heartandsoulofchange.com November, 2012
The AllianceThe of Change
The AllianceThe of Change
Alliance feedback enables a fit between client expectations, preferences, and services
Does not leave the alliance to chance—applying over 1000 studies showing the relationship of the alliance to positive outcomes
Reliance on the AllianceReliance on the Alliance
The Alliance is the Best Friend We Have in theWe Have in the Therapy Room
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40 Years of Data say…40 Years of Data say…
•Client’s rating of the rating of the alliancealliance the best predictor of the best predictor of engagement and outcomeengagement and outcome..
•Client’s subjective experience subjective experience of change early in the process of change early in the process the best predictor of success the best predictor of success for any particular pairing.for any particular pairing.
Clients drop out for 2
Quickest Way Prevent Drop Out
Quickest Way Prevent Drop Out
Clients drop out for 2 reasons: counseling is not helping (monitor outcome) & alliance problems—not engaged or turned on. Direct way to improve effectiveness isway to improve effectiveness isto keep people engaged in therapy.Gotta measure the alliance
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The Session Rating Scale Measuring the AllianceThe Session Rating Scale Measuring the Alliance
••Give at the end Give at the end of session;of session;
••Score in cm to Score in cm to the nearest mm;the nearest mm;
••Each line 10 cm Each line 10 cm in length;in length;
•Reliable, valid, feasible
••Discuss with Discuss with client anytime client anytime total score falls total score falls belowbelow 3636
The Session Rating ScaleTraditionally
The Session Rating ScaleTraditionally Told us with their feet
Will let s kno on SRS Told us with their feet
Will let s kno on SRSWill let us know on SRS before telling/bolting.
Takes work for candor. Not about trying to please, social desirability, d d h t i ti !
Will let us know on SRS before telling/bolting.
Takes work for candor. Not about trying to please, social desirability, d d h t i ti !demand characteristics!
Disparity in power & socio- economic, ethnic, or racial diff., can make it tough.
demand characteristics!Disparity in power &
socio- economic, ethnic, or racial diff., can make it tough.
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Becoming BetterA Culture of Feedback with the SRS
Becoming BetterA Culture of Feedback with the SRS
•When scheduling a first appointment, provide a rationale pp pfor seeking feedback regarding the alliance.
•Work a little differently;•Want to make sure that you are getting what you need;•Take the “temperature” at the end of each visit;each visit;•Feedback is critical to success.
•Restate the rationale prior to administering the scale.
•How not to do the SRS
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The Session Rating ScaleAn Introduction in Your Own Words
The Session Rating ScaleAn Introduction in Your Own Words
Let’s take a minute and have you fill out the th f th t k i i b t
Let’s take a minute and have you fill out the th f th t k i i b tother form that asks your opinion about our
work together. It’s kind of like taking the temperature of our relationship today. Are we too hot or too cold? Do I need to adjust the thermostat? This information helps me stay on track. The ultimate purpose of using th f i t k ibl ff t
other form that asks your opinion about our work together. It’s kind of like taking the temperature of our relationship today. Are we too hot or too cold? Do I need to adjust the thermostat? This information helps me stay on track. The ultimate purpose of using th f i t k ibl ff tthese forms is to make every possible effort to make our work together beneficial. If something is amiss, you would be doing me the best favor if you let me know. Can you help me out?
these forms is to make every possible effort to make our work together beneficial. If something is amiss, you would be doing me the best favor if you let me know. Can you help me out?
The Session Rating ScaleA Quick Visual Check
The Session Rating ScaleA Quick Visual Check
Scores < 36 or 9cms should Scores < 36 or 9cms should be discussed.
SRS is good or its not. Either thank the client for the feedback, & invite them to share future concerns; or
be discussed. SRS is good or its not. Either
thank the client for the feedback, & invite them to share future concerns; orshare future concerns; or thank client & explore why their ratings are lower so that you can fix the concern.
Building the Alliance
share future concerns; or thank client & explore why their ratings are lower so that you can fix the concern.
Building the Alliance
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With High ScoresFind Out What Went Well
With High ScoresFind Out What Went Well
What went well today f th t l d t
What went well today f th t l d tfor you that led to your high score?
What do you want to make sure that I keep d i t ti ?
for you that led to your high score?
What do you want to make sure that I keep d i t ti ?doing next time?
What did you like about how things went today?
doing next time?What did you like
about how things went today?
The Session Rating ScaleWhat About Below 36 or 9cm?
The Session Rating ScaleWhat About Below 36 or 9cm?
Don’t expect specifics o e elations an
Don’t expect specifics o e elations anor revelations—any feedback is a godsend
Is there anything else I could have done, something I should
or revelations—any feedback is a godsend
Is there anything else I could have done, something I shouldsomething I should have done more of or less of, some question or topic I should have asked?
something I should have done more of or less of, some question or topic I should have asked?
www.heartandsoulofchange.com November, 2012
The Session Rating ScaleOther Responses
The Session Rating ScaleOther Responses
When time an issue, set expectation that the SRS will
When time an issue, set expectation that the SRS willexpectation that the SRS will increase over time.
Sometimes: “I don’t know” or “Nobody’s perfect.” Or will rate you low & never say why, or rate high all the way. It’s all ok.
expectation that the SRS will increase over time.
Sometimes: “I don’t know” or “Nobody’s perfect.” Or will rate you low & never say why, or rate high all the way. It’s all ok.
Continue to leave space for feedback, to want it, and many clients will. Even if they don’t, your attention to the alliance will help. Get points for trying.
Continue to leave space for feedback, to want it, and many clients will. Even if they don’t, your attention to the alliance will help. Get points for trying.
But Don’t StressIt’s Okay
But Don’t StressIt’s Okay Keep encouraging client to
let you know Keep encouraging client to
let you knowlet you know… Have to KNOW: No bad
news. Not a measure of competence or anything negative about you or the client. Gift from the client th t h l t b b tt
let you know… Have to KNOW: No bad
news. Not a measure of competence or anything negative about you or the client. Gift from the client th t h l t b b ttthat helps you to be better.
Unless you really want it, you are unlikely to get it.
You won’t get it from everyone.
that helps you to be better. Unless you really want it,
you are unlikely to get it. You won’t get it from
everyone.
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The SRSGraceful Acceptance
The SRSGraceful Acceptance
A willingness to be flexible ll t thi d
A willingness to be flexible ll t thi dusually turn things around.
Clients reporting alliance problems more likely for success. Lower scores on the SRS should be celebrated.
usually turn things around. Clients reporting alliance
problems more likely for success. Lower scores on the SRS should be celebrated.SRS should be celebrated.
If clients are comfortable enough to express something isn’t right, then you are doing something great.
SRS should be celebrated. If clients are comfortable
enough to express something isn’t right, then you are doing something great.
What Separates The Best?Barry’s Recipe
What Separates The Best?Barry’s Recipe
1. Client Feedback Improves 1. Client Feedback Improves Outcomes More than Anything since the Beginning of Psychotherapy
2. Clients Account for Most of the Variance: Rally Recruit
Outcomes More than Anything since the Beginning of Psychotherapy
2. Clients Account for Most of the Variance: Rally Recruitthe Variance: Rally, Recruit Harvest Resources for Change
3. Rely on the Tried & True Old Friend, the Alliance
the Variance: Rally, Recruit Harvest Resources for Change
3. Rely on the Tried & True Old Friend, the Alliance