Utilizing Patient Utilizing Patient Feedback Feedback

(and Therapist Civility)(and Therapist Civility)to Improve to Improve

Psychotherapy OutcomePsychotherapy OutcomeDan BuccinoDan Buccino

JHBMCJHBMCJHUSOMJHUSOM

BPIBPIJune 27, 2006June 27, 2006

Civility and Healthcare

Through the 20th Century, science has opened the body.

Into the 21st Century, civility will reopen the person.

To do even better science. Pro-civility practice and policies

Civility and Therapy Good therapists born not made? = Good manners come from a good heart. Good therapists made not born? = Good heart comes from good manners.

Legislating civility and public health? (NYC: quality of life, tobacco, obesity)

Teaching and Practicing “Relational Competence.”

Civility and Risk Good relationship with pt and family best

prevention against malpractice suit, even if adverse event.

Injured patients 50% less likely to sue when an error was disclosed and there was an apology. (Annals Int. Med. 2004)

Move in OR & CO to make it illegal to use doctors’ apologies against them in court.

Acknowledge, apologize for outcome, not necessarily take blame.

Osler’s Golden Rule

• “Alter the Golden Rule: What you do not like when done to yourself, do not do to others.”

- Sir William Osler, JHUSOM

• “Others bruise as easily as we do.”

One Step Beyond the Golden Rule!

• Think first of others’ (comfort and convenience).

• If not OK for others, don’t insist.

• Restrain Yourself!

• “presenteeism”

87%

13%

Updating the Wheel:Updating the Wheel:Recent ResearchRecent Research

TreatmentTreatment::60% due to “Alliance” 60% due to “Alliance” and Relationship and Relationship (“common factors”: (“common factors”: 8% of 13%)8% of 13%)

•30% due to “Allegiance” 30% due to “Allegiance”

FactorsFactors (4/13%) (4/13%)

8% due to model and 8% due to model and technique (1/13%)technique (1/13%)

•Extra-therapeuticExtra-therapeutic

Wampold, B. (2001). Wampold, B. (2001). The Great Psychotherapy DebateThe Great Psychotherapy Debate. New York: Lawrence Erlbaum.. New York: Lawrence Erlbaum.

Hubble, M., Duncan, B., & Miller, S. (1999). The Heart and Soul of Change. Washington, D.C.: APA Press

Relationship FactorsRelationship Factors

•The Therapeutic The Therapeutic Alliance:Alliance:

•Agreement on Agreement on goals;goals;•Agreement on Agreement on tasks;tasks;•““Rogerian” core Rogerian” core conditions.conditions.

60 %60 %

(R+H+P) Formula for Success(R+H+P) Formula for Success

Practitioners’ Contributions:Practitioners’ Contributions:

RRelationshipelationship

HHope and aope and a

PPlanlan

Super ShrinksSuper Shrinks

Do better than other therapists. Do better than other therapists. Period. Regardless of caseload mix, Period. Regardless of caseload mix, severity, training, experience, severity, training, experience, degree, etc.degree, etc.

Interpersonal facilitative skills Interpersonal facilitative skills

(civility) best.(civility) best.

Most open to feedbackMost open to feedback..

Therapy Effectiveness Super Shrinks effective with 75%. Least effective with 25%. Improve least effective by 65% with active,

formal patient feedback (re customer satisfaction, service, and outcome).

Least effective can then become effective with 41% of cases.

All therapy works sometimes with some patients.

What will work with this patient and this therapist at this time?

•Scored to the Scored to the nearest nearest millimeter.millimeter.

•Add the four Add the four scales together scales together for the total score.for the total score.

•Client places a Client places a hash mark on hash mark on the line.the line.

•Each line 10 cm Each line 10 cm (100 mm) in (100 mm) in length.length.

The Outcome Rating ScaleThe Outcome Rating Scale

•Scored to the Scored to the nearest nearest millimeter.millimeter.

•Add the four Add the four scales together scales together for the total score.for the total score.

•Client places a Client places a hash mark on hash mark on the line.the line.

•Each line 10 cm Each line 10 cm (100 mm) in (100 mm) in length.length.

The Session Rating ScaleThe Session Rating Scale

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JHBMC Student Therapist Outcomes 2003-06

9 students; passive collection of data N=89 cases (n=75 ≥2 sessions) Mean # sessions: 6.4 Mean intake ORS: 18.9 Mean D/C ORS: 25.1 (recovered ≥ 25

clinical cutoff) Mean RCI: 6.2 (improved ≥ 5 points)

JHBMC Student Therapist Outcomes 2003-06 (cont’d)

48% improved (RCI ≥5) (36/75) 59% recovered (D/C ORS ≥25) (44/75) 86% of improved also recovered (31/36) Preliminary data 6/26/06 Progress comes quickly. Tx is beginning

of end. Deterioration comes over time.

JHBMC Student Therapist Outcomes 2003-06 (cont’d)

Mean RCI with intake ORS < 25 (clinical cutoff) (72%, 54/75) : 9.7 (cf. 6.2)

More symptomatic populations improve more in tx.

61% (33/54) improve. 50% (27/54) recover. Big improvements even without

complete recovery. Therapy works!

JHBMC Student Therapist Patient Satisfaction 2003-06

9 students; passive collection of data N=89 cases (n=75 ≥ 2 sessions) Mean # sessions: 6.4 Mean intake SRS: 34 Mean D/C SRS: 35.6 Preliminary data 6/26/06

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Thank You!Thank You!

Questions, comments, concerns?Questions, comments, concerns?

Dan BuccinoDan Buccino

410.550.0105410.550.0105

DBuccino@jhmi.eduDBuccino@jhmi.edu

Counterintuitive Civility

It may be simple, but it’s not easy. Common sense isn’t always common

practice. Changing surface changes depth.

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