on becoming a better therapist, chapter 3 handout slides

heartandsoulofchange.com June 12, 2015

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On Becoming a Better TherapistChapter Three

How Being Bad Can Make You Better How Being Bad Can Make You Better

Barry Duncan, Barry Duncan, Psy.DPsy.D. . heartandsoulofchange.comheartandsoulofchange.com561.239.3640 [email protected] [email protected]


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Why You Should Do PCOMS: The 6 Rationales

1. Solves the problems of unreliable outcomes, d t d th i t i bilit i

1. Solves the problems of unreliable outcomes, d t d th i t i bilit idropouts, and therapist variability via identification of non-responding clients

2. Supported by 5 RCTs 3. A proven quality improvement strategy4 Enhances the factors related to success

dropouts, and therapist variability via identification of non-responding clients

2. Supported by 5 RCTs 3. A proven quality improvement strategy4 Enhances the factors related to success4. Enhances the factors related to success5. Incorporates the known predictors of success

(early change and the alliance)6. And…

4. Enhances the factors related to success5. Incorporates the known predictors of success

(early change and the alliance)6. And…

Operationalizes Client Privilege and Social Justice

• Puts the consumer’s voice t t th lcenter stage…the only

system that is collaborative by design

• Allows services to be consumer driven; bringsconsumer driven; bringsthem into the inner circle of decision-making

• Partners in recovery-driven services


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The Story Goes…Clients Don’t Improve Because

The Story Goes…Clients Don’t Improve Because

They are resistant, too sick, They are resistant, too sick, traumatized or whatever the latest explanations. Or, the therapist is not masterful, lacks experience or hasn’t learned the latest & greatest.

traumatized or whatever the latest explanations. Or, the therapist is not masterful, lacks experience or hasn’t learned the latest & greatest.learned the latest & greatest.

Shoot the client or therapist. Take your pick. I pick neither. I choose to follow the wisdom of a sage therapist.

learned the latest & greatest. Shoot the client or therapist.

Take your pick. I pick neither. I choose to follow the wisdom of a sage therapist.

Granted at first

Sage Psychotherapy Scholar:Mae West?

Granted, at first blush, these hardly seem like words for us to live by—but, as

When I’m good, I’m very good, b t hen live by but, as

it turns out, they are.

but when I’m bad, I’m better.


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Becoming Better Identifying Clients Not Responding

Becoming Better Identifying Clients Not Responding

When outcome is bad i h d

When outcome is bad i h din other words, you can make it better by changing something about the therapy to turns things around;

in other words, you can make it better by changing something about the therapy to turns things around;turns things around; and if things don’t turn around, by moving the client on to a different provider or service

turns things around; and if things don’t turn around, by moving the client on to a different provider or service

Becoming Better Two Choices

Becoming Better Two Choices

Either the client is i i t If t

Either the client is i i t If timproving or not. If not, the client is at risk.

Engage client in discussion about progress, and what should be done differently

improving or not. If not, the client is at risk.

Engage client in discussion about progress, and what should be done differentlyshould be done differently if there isn’t any.

Keeps clients engaged so that a new direction can be planned.

should be done differently if there isn’t any.

Keeps clients engaged so that a new direction can be planned.


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Becoming BetterWhen I’m Good, I’m Very Good

Becoming BetterWhen I’m Good, I’m Very Good

When ORS scores When ORS scores increase, when you’re good, a crucial step to be very good is help clients see gains as a consequence of their

increase, when you’re good, a crucial step to be very good is help clients see gains as a consequence of theirconsequence of their own efforts and make sense of its meaning so repeat in the future.

consequence of their own efforts and make sense of its meaning so repeat in the future.


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The ORS: Reliable and Clinically Significant Change

Reliable ChangeReliable Change: Exceeds : Exceeds maturation, chance, and maturation, chance, and measurement error: 6 on measurement error: 6 on the ORS; the ORS; Clinically Clinically Significant ChangeSignificant Change: A: ASignificant ChangeSignificant Change: A : A change of 6 plus crossing change of 6 plus crossing the clinical cut off of 25the clinical cut off of 25

Use PCOMS to Focus on Change


Notice the changeNotice the change!! Ask Ask about and be curious about about and be curious about

Notice the changeNotice the change!! Ask Ask about and be curious about about and be curious about change: How did you do change: How did you do that? Where did that idea that? Where did that idea come from?come from?

Validate the clients Validate the clients contribution to change.contribution to change.

change: How did you do change: How did you do that? Where did that idea that? Where did that idea come from?come from?

Validate the clients Validate the clients contribution to change.contribution to change.How is (drug/How is (drug/txtx program) program) helping access helping access resources resources that have always been there that have always been there but were just beyond your but were just beyond your grasp? Change builds Heroic grasp? Change builds Heroic StoriesStories

How is (drug/How is (drug/txtx program) program) helping access helping access resources resources that have always been there that have always been there but were just beyond your but were just beyond your grasp? Change builds Heroic grasp? Change builds Heroic StoriesStories


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Becoming BetterGraphs: A Helpful Visual

Becoming BetterGraphs: A Helpful Visual

Adds a visual t

Adds a visual tcomponent—a way

to focus tx At a glance tells the

story of the client’s progress.

component—a way to focus tx

At a glance tells the story of the client’s progress.progress.

Indispensable with couples & families, discussing multiple viewpoints

progress. Indispensable with

couples & families, discussing multiple viewpoints

Casts clients in their rightful


roles as heroes/heroines of their own journeys. Shine a spotlight on changes & request that the client take

b f hi ha bow for his or her creativity, courage, & action

Harold


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Becoming BetterLinking Outcome to Process

••See clients See clients moremorefrequently when thefrequently when thefrequently when the frequently when the slope of change is slope of change is steep.steep.••Begin to space the Begin to space the visits as the rate of visits as the rate of change lessens.change lessens.gg••See clients as long See clients as long as there is as there is meaningful change meaningful change & they desire to & they desire to continue.continue.

Reviewing GraphsOver Utilization

Reviewing GraphsOver Utilization

When max benefit reached, talk about stepping down; not

When max benefit reached, talk about stepping down; not pp g ;discharge, but planning for continued recovery out of tx.

If not stepped down, graphs look like a saw, rising and falling with everyday life; li t di d

pp g ;discharge, but planning for continued recovery out of tx.

If not stepped down, graphs look like a saw, rising and falling with everyday life; li t di dclients are disempowered

ORS represents life in general instead of client's perceptions connected to the purpose of the service.

clients are disempowered

ORS represents life in general instead of client's perceptions connected to the purpose of the service.


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Becoming BetterDoesn’t Mean All Therapy Should Be Brief

Becoming BetterDoesn’t Mean All Therapy Should Be Brief

Au contraire, research h i

Au contraire, research h isuggests that more is

better than less for clients who progress early & want to continue.

When little or change

suggests that more is better than less for clients who progress early & want to continue.

When little or changeWhen little or change, however, same data indicates that therapy should, indeed, be as brief as possible.

When little or change, however, same data indicates that therapy should, indeed, be as brief as possible.

Involve the client in Involve the client in

Becoming BetterWhat to Do NextBecoming BetterWhat to Do Next

monitoring progress & the decision about what to do next, to elicit his or her ideas & formulate a plan.

The discussion repeated in all

monitoring progress & the decision about what to do next, to elicit his or her ideas & formulate a plan.

The discussion repeated in all The discussion repeated in all meetings, but later ones gain significance and warrant additional action: Checkpoint and Last Chance Discussions.

The discussion repeated in all meetings, but later ones gain significance and warrant additional action: Checkpoint and Last Chance Discussions.


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Okay, so things haven’t changed since Okay, so things haven’t changed since

Becoming BetterClient Not Improving

Becoming BetterClient Not Improving

the last time we talked. How do you make sense of that? Should we be doing something different here, or should we continue on course steady as we go? If

the last time we talked. How do you make sense of that? Should we be doing something different here, or should we continue on course steady as we go? If we are going to stay on the same track, how long should we go before getting worried? When will we know when to say “when?”

we are going to stay on the same track, how long should we go before getting worried? When will we know when to say “when?”

Becoming BetterWhen to Say WhenBecoming Better

When to Say WhenStimulates both client

d th i t tStimulates both client

d th i t tand therapist to struggle with continuing a process that is yielding little or no benefit.

and therapist to struggle with continuing a process that is yielding little or no benefit.

To support what is working & challenge what is not. Urgency increases over time

To support what is working & challenge what is not. Urgency increases over time


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Determining Checkpoint and Last Chance: The Work of Ken Howard

Collect ORS data on all clients for at least 6 months. Separate the successful from the unsuccessful outcomes, noting the session at which each met or exceeded 6 points. An alternative that also incorporates clients who take longer to achieve RC is to note the session at hich clients begin the change40

5060708090

100

session at which clients begin the change.Chart the results on a graph with the number of sessions increasing along the bottom (x-axis) and the

percent of successful clients along the side (y-axis).010203040

1 2 3 4 5 6 7

Checkpoint Session: An Opportunity to Be Better

Checkpoint Session: An Opportunity to Be Better

B t tB t tBe transparent—comment about the lack of progress and seek feedback from

Be transparent—comment about the lack of progress and seek feedback from the client about what he/she thinks it meansthe client about what he/she thinks it means


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Becoming Better First, the AllianceBecoming Better First, the Alliance

“It doesn’t look like we are “It doesn’t look like we are getting anywhere. Let’s go over the SRS to make sure you are getting exactly what you are looking for.” Going thru SRS and eliciting

getting anywhere. Let’s go over the SRS to make sure you are getting exactly what you are looking for.” Going thru SRS and eliciting g gclient responses in detail can help you & the client get a better sense of what may not be working.

g gclient responses in detail can help you & the client get a better sense of what may not be working.


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Checkpoint ConversationDo Something DifferentCheckpoint ConversationDo Something Different

Nothing may come of talk about the alliance Don’t

Nothing may come of talk about the alliance Don’tabout the alliance. Don t worry. Making effort helps.

Invite others from support system, use a team or co-therapist, a different approach; referral to another

about the alliance. Don t worry. Making effort helps.

Invite others from support system, use a team or co-therapist, a different approach; referral to another pphelper, religious advisor, or self-help group—whatever seems of value.

Any ideas are implemented, and progress is monitored.

pphelper, religious advisor, or self-help group—whatever seems of value.

Any ideas are implemented, and progress is monitored.

Becoming Better First, the Alliance

Carly…client goalsCarly…client goals

Matt…another approach

Ken…client’s theory of change


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Becoming BetterPrecipitous DropsBecoming BetterPrecipitous Drops

Is the drop related to the reason for service a

Is the drop related to the reason for service areason for service—a deterioration—or is a recent event holding sway over the client’s rating?

If deterioration then a red

reason for service—a deterioration—or is a recent event holding sway over the client’s rating?

If deterioration then a red If deterioration, then a red flag, signals the necessity to have a heart to heart about what needs to happen different to quickly turn things around.

If deterioration, then a red flag, signals the necessity to have a heart to heart about what needs to happen different to quickly turn things around.

Becoming Better Potholes Are Different

Becoming Better Potholes Are Different

Hit a pot hole, etc. Events h ld ti

Hit a pot hole, etc. Events h ld tihold sway over rating.

If pothole, ask to redo looking at the whole week, related to reasons for tx.

If pothole trumps the orig

hold sway over rating. If pothole, ask to redo

looking at the whole week, related to reasons for tx.

If pothole trumps the orig If pothole trumps the orig. reasons for tx, then go with it. Reconnect new issues to ORS. Don’t turn life events into “issues.” Keesha

If pothole trumps the orig. reasons for tx, then go with it. Reconnect new issues to ORS. Don’t turn life events into “issues.” Keesha


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Becoming Better The Last Chance Discussion


Driving into desert Driving into desert grunning on empty, “last chance for gas.”

Depicts the necessity of stopping and discussing the

grunning on empty, “last chance for gas.”

Depicts the necessity of stopping and discussing thediscussing the implications of continuing w/o change.

discussing the implications of continuing w/o change.

Becoming Better Never the LAST CHANCE

Becoming Better Never the LAST CHANCE

Doesn’t mean the “last chance” fo

Doesn’t mean the “last chance” fo“last chance” for your client—but rather the last chance of a change plan or pairing. No

“last chance” for your client—but rather the last chance of a change plan or pairing. No p p glast chance for your client—referral can make the difference!

p p glast chance for your client—referral can make the difference!


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1. What does the client say?

Last Chance ThoughtsThe Longer w/o Change, the Quicker to #6

y2. Is the client engaged?3. What have you done

differently so far?4. What can be done

differently now?5. What other resources can

be rallied?6. Time to fail successfully?


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At the least, consultation At the least, consultation Referral seriously discussed. Rarely justified to continue

past typical period. Rarely is not never. Highly

idi ti & i l

Referral seriously discussed. Rarely justified to continue

past typical period. Rarely is not never. Highly

idi ti & i lidiosyncratic & uniquely negotiated. Keeps us honest, addresses the lack of change transparently—new for me.

idiosyncratic & uniquely negotiated. Keeps us honest, addresses the lack of change transparently—new for me.

When I’m Bad, I’m BetterFailing Successfully

When I’m Bad, I’m BetterFailing Successfully

Repeat commitment to Repeat commitment to phelp them achieve goals.

Failure says nothing about them or their potential.

If client wants, meet until

phelp them achieve goals.

Failure says nothing about them or their potential.

If client wants, meet until If client wants, meet until arrangements are made.

But rarely continue with clients who show no improvement…Alina

If client wants, meet until arrangements are made.

But rarely continue with clients who show no improvement…Alina


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100

My Data

405060708090P

ercent reaching

%

98%

0102030

1 2 3 4 5 6 7

target

75%

Failing SuccessfullyFailing Successfully

Change of Therapist


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28.9

Watershed ClientFailing SuccessfullyWatershed Client

Failing Successfully

I believed in PCOMS, but… I believed in PCOMS, but… I wish my helper had failed successfully

Awakened me to the pitfalls; taught me to fail successfully.

Avoid a “chronic” client—the iatrongenic effects of

Awakened me to the pitfalls; taught me to fail successfully.

Avoid a “chronic” client—the iatrongenic effects ofthe iatrongenic effects of continuing therapy w/o benefit.

ORS allows us to ask ourselves hard questions.

the iatrongenic effects of continuing therapy w/o benefit.

ORS allows us to ask ourselves hard questions.


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Becoming Better Guard Against Finger Pointing

Becoming Better Guard Against Finger Pointing

Guard against explaining li t th

Guard against explaining li t thclient response thru

theoretical filters & folklore— puts us right back where we have traditionally been—attributing lack of change

client response thru theoretical filters & folklore— puts us right back where we have traditionally been—attributing lack of changeattributing lack of change to the client. Client non-response means something else should be done.

attributing lack of change to the client. Client non-response means something else should be done.

Another Pitfall of not Focusing on Change Is “Supportive” TherapyAnother Pitfall of not Focusing on Change Is “Supportive” Therapy

Client “needs” maintenance work, l ti hi i h fi i

Client “needs” maintenance work, l ti hi i h fi irelationship is enough: finger in

the dike services Therapy devolves to a place to

hang out, talk, receive support, & combat loneliness.

relationship is enough: finger in the dike services

Therapy devolves to a place to hang out, talk, receive support, & combat loneliness.combat loneliness.

Therapy can do these things, but it should also create the possibility for clients to attain these benefits in the community

combat loneliness. Therapy can do these things, but

it should also create the possibility for clients to attain these benefits in the community


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Dependency and HelplessnessIatrogenic Effects

Dependency and HelplessnessIatrogenic Effects

Without an aspiration Without an aspiration toward helping clients achieve more independence, therapy can be a disservice to clients—creating

toward helping clients achieve more independence, therapy can be a disservice to clients—creatingclients creating dependency and fostering a client identity of helplessness and pathology

clients creating dependency and fostering a client identity of helplessness and pathology

Becoming Better Feedback Is My Compass

Becoming Better Feedback Is My Compass

Not an uninhabited terrain of technical procedures, nor the

Not an uninhabited terrain of technical procedures, nor the p ,predictable path of diagnosis, prescription, & cure. Cannot be described w/o the client & therapist, co-adventurers in a journey across uncharted territory. Common factors provide landmarks for this

p ,predictable path of diagnosis, prescription, & cure. Cannot be described w/o the client & therapist, co-adventurers in a journey across uncharted territory. Common factors provide landmarks for thisprovide landmarks for this interpersonal & idiosyncratic trip, & specific models provide well-traveled directions to consider, but feedback provides the compass, showing the way to the desired destination.

provide landmarks for this interpersonal & idiosyncratic trip, & specific models provide well-traveled directions to consider, but feedback provides the compass, showing the way to the desired destination.


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Being BadCan Make You Better

Being BadCan Make You Better

Helps clients you are already ff ti ith b i

Helps clients you are already ff ti ith b ieffective with by empowering

change—helps those not benefiting by enabling other options and, in absence of change, the ability to move the client on.

effective with by empowering change—helps those not benefiting by enabling other options and, in absence of change, the ability to move the client on.the client on.

When we’re good, we’re very good, but when we’re bad, we can be even better.

the client on.

When we’re good, we’re very good, but when we’re bad, we can be even better.

What People ForgetWhat People Forget

Not Just Flicking a Form…A Cli i l P F ll

Not Just Flicking a Form…A Cli i l P F ll A Clinical Process Fully Integrated into the Work Itself

Like any Clinical Process, Success Rests on the Therapist: Have to Believe in It, Use It

A Clinical Process Fully Integrated into the Work Itself

Like any Clinical Process, Success Rests on the Therapist: Have to Believe in It, Use ItHave to Believe in It, Use It Sincerely, Make It Their Own

Worthless Unless Data Are Used to Identify at Risk Clients…and then Do Something about Them.

Have to Believe in It, Use It Sincerely, Make It Their Own

Worthless Unless Data Are Used to Identify at Risk Clients…and then Do Something about Them.

on becoming a better therapist, chapter 3 handout slides

Education

better therapist chapter

sage therapist

therapist variability

d t d th

things dont

clients dont

im bad

things aroundturns things