reach slides handout day ii (2 slides per pg miller & chow, 16)

5/5/16%

1%

Sco)%D.%Miller,%Ph.D.%Interna8onal%Center%for%Clinical%Excellence%

Daryl%L.%Chow,%Ph.D.%Interna8onal%Center%for%Clinical%Excellence%

REACHPushing Your Clinical Effectiveness to the Next Level

The%Evolu8on%of%Psychotherapists:%Agenda%

Iden8fying%What%&%How%to%Improve%

The%Prac8cal%Applica8on%of%Deliberate%Prac8ce%

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2%

The%Evolu8on%of%Psychotherapy:%

Goal%for%Today%

The%Prac8cal%Applica8on%of%Deliberate%Prac8ce%

The%Evolu8on%of%Psychotherapists:%Exercise%

Bridging%

• Review&your&taxonomy;&

• Iden3fy&the&prac3cal&&&psychological&

barriers&

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3%

The%Evolu8on%of%Psychotherapists:%Exercise%

• Look&into&the&crystal&ball&

•  Learning Plan•  Coach•  Immediate Feedback•  Successive Refinement

Individualized+Learning+Objec3ves+

Feedback+

A+Coach+

Repe33on+

Ericsson, K. A. (2006). The Influence of experience and deliberate practice on the development of superior expert performance. In The Cambridge handbook of expertise and expert performance. (pp. 683-703). Cambridge: Cambridge University Press. Chow, D. (2016). The Practice and the Practical: Pushing Your Clinical Effectiveness to the Next Level. Book chapter in Reaching for Excellence- Feedback-Informed Treatment in Practice Miller, S. D., Hubble, M., Chow, D. (2016): Professional Development: From Oxymoron to Reality. Book chapter in The Cycle of Excellence

Deliberate Practice

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4%

FIT$Supervision$Training$

Watkins,$C.E.$(2011).%%Does%psychotherapy%supervision%contribute%to%pa8ent%outcomes:%Considering%30%years%of%Research.%The&Clinical&Supervisor,&30(2),%235W256.%Hill,$C.,$&$Knox,$S.$(2013).%%Training%and%Supervisions%in%Psychotherapy.%%(pp.%775W809).%%In%M.J.$Lambert$(ed.).$$Bergin&and&Garfield’s&Handbook&of&Psychotherapy&and&Behavior&Change,&6th&Edi3on.%%New%York:%Wiley.%

• Defined%as,%“a%rela8onship%between%a%supervisor%and%supervisee%that%promotes%the%professional%development%of%the%supervisee%through%interpersonal%processes,%including%mutual%problemWsolving,%instruc8on,%evalua8on,%mentoring,%and%role%modeling”%(p.%785).%

• As&of&today,&there&is&one&experimental&

study&(Bambling&et&al.,&2006)&in&the&

literature.&


• As%regard%effec8veness,%Watkins%(2011)%review%concluded:%%

“We%do%not%seem%to%be%any%more%able%to%say%now%(as%opposed%to%30%years%ago)%that%psychotherapy%supervision%contributes%to%pa8ent%outcome.”%

• Evidence%to%date%indicates%that%supervision%enhances%supervisee:%%

• SelfWawareness;%• Treatment%knowledge;%• Skill%acquisi8on%and%u8liza8on;%• SelfWefficacy.%

%

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5%


Rousmaniere%et%al.%(2015)%examined%the%impact%of%supervisors%on%outcome:%%

•  175&therapists,&23&clinicians,&6521&clients;&

•  Outcome&measured&at&each&session;&

•  5&years&of&data&from&a&nonVprofit&

treatment&center.&

Rousmaniere,$T.,$SwiG,$J.,$Wagner,$R.,$Whipple,$J.,$&Berzins,$S.%(2014).%%Supervisor%variance%in%psychotherapy%outcome%in%rou8ne%prac8ce.%%Psychotherapy&Research,&DOI:%10.1080/10503307.2014.963730.%

Supervisors%explained%less%than%1%%of%the%variance%in%client%outcomes.%

The%Evolu8on%of%Psychotherapists:%The%“Good”%Coach%

•  The%Missing%Half;%•  Why%tradi8onal%supervision%doesn't%

work?%1. %TheoryWTalk;%2. PatWonWtheWback;%3. Lack%of%Monitoring%Progress%%4. Lack%of%Monitoring%Impact%of%Supervision;%

5. Not%Analyzing%the%Game,%&%6. Lack%of%Learning%Objec8ves%

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6%


1. Reach%for%the%TOP;%2. Interview%Several%


•  Be clear about what you want help with;•  Someone who gives short, clear directions;•  Someone who loves teaching fundamentals;•  Willing to analyze your game;•  More corrective than critical;•  Process versus technique/tricks;•  An authority, not authoritarian;•  Able to distinguish when any challenges

encountered are a result of you and your growth edge, or the coaching;

•  How to become a better version of you, not a version of the coach.

•  Help you stay at your growth edge;

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7%

Panic Zone


Learning Zone

Comfort Zone

The%Evolu8on%of%Psychotherapists:%The%“Good”%Coach%Exercise%

YOUR$COACH$

•  Who$would$you$connect$with?$Dream$Coach/s?%

•  What$would$prevent$you$from$reaching$out$(Barriers)?%

•  How$would$you$know$you’ve$made$the$wrong$decision?%

5/5/16%

8%

The%Evolu8on%of%Psychotherapists:%Other%Resources%

Deliberate$PracXce$

BASICS%Miller,$S.D.,$&$Hubble,$M.A.$(2011).%%The%road%to%mastery.%%The&Psychotherapy&Networker,&35(2),%22W31,%60.%

5/5/16%

9%

The 80/20 Rule

Wampold,%B.,%&%Imel,%Z.%(2015).%%The&Great&Psychotherapy&Debate.%%New%York:%Lawrence%Erlbaum.%

Goals,%%Meaning%or%Purpose%

Client’s%View%of%the%%Rela8onship%

Means%or%Methods%

Client%Preferences%

BASICS%

5/5/16%

10%

• Baldwin%et%al.%(2007):%%

• Study&of&331&consumers,&81&

clinicians.&

&

• Therapist&variability&in&the&alliance&predicted&outcome.&

&

• Consumer&variability&in&the&

alliance&unrelated%to&outcome.&

Baldwin,%S.,%Wampold,%B.,%&%Imel,%Z.%(2007).%%Untangling%the%AllianceWOutcome%Correla8on.%Journal&of&Consul3ng&and&Clinical&Psychology,&75(6),%842W852.%

Goals,%%Meaning%or%Purpose%

Client’s%View%of%the%%Rela8onship%

Means%or%Methods%

Client%Preferences%

BASICS%

Anderson,$T.$Ogles,$B.,$Lambert,$M.,$Vermeersch,$D.%(2009).%%Therapist%effects:%Facilita8ve%interpersonal%skills%as%a%predictor%of%therapist%success.%%Journal&of&Clinical&Psychology,&65(7),%755W768.%

• Researchers%Anderson,%Ogles,%Lambert%&%Vermeersch%(2009):%%

• 25&therapists&trea3ng&1100+&clients;&• Variety&of&demographic&variables;&

• Measure&of&interpersonal&skills&(SSI).&

• DomainWspecific%interpersonal%knowledge%tested%by%using%therapist%responses%to%challenging%therapeu8c%interac8ons:%

• Four&problema3c&therapeu3c&process&

segments;&

• Mul3ple&challenging&interpersonal&pa_erns&

(e.g.,&angry,&dependent,&confused,&blaming,&

controlling,&etc.).&

BASICS%

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11%

Anderson,$T.$Ogles,$B.,$Lambert,$M.,$Vermeersch,$D.%(2009).%%Therapist%effects:%Facilita8ve%interpersonal%skills%as%a%predictor%of%therapist%success.%%Journal&of&Clinical&Psychology,&65(7),%755W768.%

• Considerable%differences%in%outcome%between%clinicians%(~9%):%

• Age,&gender,&percentage&of&work&3me&spent&conduc3ng&

therapy,&theore3cal&orienta3on&

not&correlated&with&outcome;&

• General&interpersonal&skills&not&correlated&with&outcome;&

• Only&domainVspecific&

interpersonal&knowledge&

predicted&outcome&

• Researchers%Anderson,%Ogles,%Lambert%&%Vermeersch%(2009):%%

• 25&therapists&trea3ng&1100+&clients;&• Variety&of&demographic&variables;&

• Measure&of&interpersonal&skills&(SSI).&

• DomainWspecific%interpersonal%knowledge%tested%by%using%therapist%responses%to%challenging%therapeu8c%interac8ons:%

• Four&problema3c&therapeu3c&process&

segments;&

• Mul3ple&challenging&interpersonal&pa_erns&

(e.g.,&angry,&dependent,&confused,&blaming,&

controlling,&etc.).&

BASICS%

The Difficult Conversations in Therapy (DCT) Training Exercise%

Chow,$D.$L.;$Lu,$S;$Owen,$J;$Miller,$S.$D.$(2016):%Difficult%conversa8ons%in%therapy%(DCT):%Can%psychotherapists%learn%in%an%environment%of%immediate%feedback%with%simulated%client%video%vigne)es?%(manuscript%in%prepara8on)%

5/5/16%

12%

Two IssuesDeliberate$PracXce$

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13%

Types of Feedback

Performance%Feedback%%

(PF)%

Learning%%Feedback%(LF)%

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14%

Content Knowledge

Conditional Knowledge

Process Knowledge

Focus on the Micro to Get the Macro


Feedback+

A+Coach+

Repe33on+

Deliberate$PracXce$

5/5/16%

15%

INSTRUCTIONS

T1 T2 T3 T4 T5

IndividualSelf-ReflectNo Feedback

Small%Groups%Brainstorm%Different Video

Reflect FeedbackShare Individual

Self-ReflectComposite as a Group

At the End: Rate & Debrief


Feedback+

A+Coach+

Repe33on+

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16%

EXPLICIT%&%IMPLICIT%

EMOTIONS%Target of Client’s Emotions

Tier 1 Feedback

Did&you&address&the&following?&

Compassionate%A)empt%to%Relate%

Disarm

by AgreementTaking%Ownership%

Tier 2 FeedbackDid&you&address&the&following?&

Sugges8ng%Alterna8ves/Possibili8es%for%the%Future%

Punctuation of Critical Juncture of TherapyReconnec8n

g%with%Clien

t’s%

Goal(s)%

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17%

Tier 3 FeedbackDid&you&address&the&following?&

Point%Ou

t%Recurre

nt%

Themes%

Express%Respect%&%Care%for%Client%

Deliberate$PracXce$

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18%

Emo8onal%Expression%

•  This item rates the energy and emotion in the participant's response. This item rates the extent to which the participant’s response is delivered with effective expressions of emotion.

Warmth,%Acceptance,%&%Understanding%(WAU)%

•  This item is a rating of the ability of the participant to care for and accept the other. Therapist behaviors/attitudes that might indicate an absence of acceptance and understanding include: a judgmental attitude, condescension, rudeness, disapproval, guilt-induction, exasperation, or annoyance.

•  Often it will be necessary to avoid rating what the participant is doing (e.g., giving advice), but rate how it is being done. Note that accepting does not necessarily mean approval, but rather a caring attitude and determination to help the other.

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Empathy%(E)%

•  The capacity to respond with an expressed understanding of the subjective experience of the client. The response must also convey an accurate understanding of the thoughts and emotions expressed in the video clip. Therefore, it is especially important that the rater have an accurate understanding of the client’s experiences in the video clips.

Alliance%Bond%Capacity%(ABC)%

•  This item rates the participant's capacity to provide a collaborative environment, one in which there is recognition of the need to work with the client jointly on problems.

5/5/16%

20%

Focused%Emo8onal%

Intona8on%

Slowing%Down%at%Key%Emphasis%

Emotional Expression

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21%

Warmth, Acceptance, Understanding

Express%Respect%&%Care%for%Client%

Taking%Ownership%Compassionate%A)empt%to%Relate%

Disarm by Agreement

Inten8on%vs.%Effects%

EXPLICIT%&%IMPLICIT%

EMOTIONS%

Target of Client’s Emotions

Deepening%of%Specific%Empathic%Response%

Point%Out%Recurrent%Themes%

Empathy

5/5/16%

22%

Collaboration

Sugges8ng%Alterna8ves/

Possibili8es%for%the%Future%

Punctuation of Critical Juncture of Therapy

Clarifica8on:%Check%for%Fit% Invita8on%for%Future%

Collabora8on%

Reconnec8n

g%with%Clien

t’s%

Goal(s)%

Sample%from%a%DCT%Par8cipant%

“Seems like you’re very upset with me and you feel that i’m not responding to you in ways that you expect me to?So, from what you have, i’m just thinking, there seems to be some similarity in how you are reacting to me just like how you’re reacting to your friends outside like you were telling me in the last two sessions, just wondering whats that about?”

FIS: 10/20Self-Rating: 2/10External-Rating: 3.5/10

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23%

12! 13!16! 17! 17!

0!

5!

10!

15!

20!

25!

T1! T2! T3! T4! T5!

Facilitative Interpersonal Skills Total Scores

1! 2! 3! 4! 5! 6! 7! 8! 9! 10! AVERAGE!

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Exemplary%Improvement%

“Hey Annie, I can hear that you’re very angry [explicit emotion] with me [target of emotion]. You know I think you must have felt very disappointed [implicit emotion] with me cos I could imagine how dismissed and alone [implicit emotion] you felt when you were crying there and needed some comfort, but all I was doing was just sitting there and nod. I must have failed you, just like your friends and therapists [disarming by agreement; compassionate attempt to relate]. II’m really sorry to have caused you to feel this way [taking ownership]…

Exemplary%Improvement%(cont.)“…I know at this point, you must be thinking that, doubting how helpful it will be to continue or changing therapists [punctuation of critical juncture in therapy], but I really hope that you could give us another chance to work together, so that I could learn to show you that I care about you better, by being more explicit and tell you I hear how you feel when you are crying. And perhaps we could also work on how to help you express your disappointment, your feelings, your needs to the others in your life outside of this session [pointing out recurrent themes], just like what you did just now. I’m really appreciative of you being so honest and sharing this with me, so I hope that we could work together to do this, you know, to others outside your life [pointing out recurrent themes; invitation for cute collaboration]. So that your voice could always be heard, and you being respected [reconnecting with client’s goals; compassionate attempt to relate].”

FIS: 20/20Self-Rating: 5/10External-Rating: 8.75/10

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25%

•  GLM (Repeated measures): Signif Main Pre-Post Training Effects, F(1, 9) = 33.98, p<.001, partial eta-squared =.791;!

•  Effect Size: Hedge's g (unbiased) : 2.37 (95% CI: 3.22 to 1.52) !

•  Nil signif correlations with participants’ self-assessment and FIS scores;!

•  Yrs of Exp not a signif predictor to performance.!

•  Helpfulness of DCT Training: M = 6 (SD: .99) (Ratings: 1 to 7);!

•  Further longitudinal & case series design analysis. !

Results!

10%

11%

12%

13%

14%

15%

16%

17%

18%

19%

1% 2% 3%

Low%

Moderate%

High%

Grouping$ %% FOS$UXlity$ FOS$Social$Awareness$

Low% %% 19.33% 20.00%

Moderate% %% 22.25% 20.75%

High% %% 23.33% 15.67%

%% %% %% %%

Effect%Size%comparisons%(Pooled%SDs)% %% %% %%

Low%v%Moderate% %% W1.19% W0.23%

Low%v%High% %% [1.63$ 1.30%

Moderate%v%High% %% W0.44% 1.53$

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26%

Therapist’s%Anxiety%in%Difficult%Interac8ons%

1.  Myth:%“I%must%know%the%answer%to%everything”;%

2.  Most%therapist%discomfort%with%anger%directed%at%him/her;%

3.  Pisall:%“moving forward…”%too%quickly.%

Unconscious Conscious

5/5/16%

27%

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reach slides handout day ii (2 slides per pg miller & chow, 16)

Healthcare