Upload
barry-duncan
View
70
Download
0
Tags:
Embed Size (px)
Citation preview
heartandsoulofchange.com June 12, 2015
pcoms.com 1
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]
heartandsoulofchange.com June 12, 2015
pcoms.com 2
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
heartandsoulofchange.com June 12, 2015
pcoms.com 3
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.
heartandsoulofchange.com June 12, 2015
pcoms.com 4
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.
heartandsoulofchange.com June 12, 2015
pcoms.com 5
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.
heartandsoulofchange.com June 12, 2015
pcoms.com 6
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
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
heartandsoulofchange.com June 12, 2015
pcoms.com 7
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
Use PCOMS to Focus on Change
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
heartandsoulofchange.com June 12, 2015
pcoms.com 8
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.
heartandsoulofchange.com June 12, 2015
pcoms.com 9
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.
heartandsoulofchange.com June 12, 2015
pcoms.com 10
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
heartandsoulofchange.com June 12, 2015
pcoms.com 11
100
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
heartandsoulofchange.com June 12, 2015
pcoms.com 12
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.
heartandsoulofchange.com June 12, 2015
pcoms.com 13
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
heartandsoulofchange.com June 12, 2015
pcoms.com 14
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
heartandsoulofchange.com June 12, 2015
pcoms.com 15
Becoming Better The Last Chance Discussion
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!
heartandsoulofchange.com June 12, 2015
pcoms.com 16
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?
heartandsoulofchange.com June 12, 2015
pcoms.com 17
Becoming Better The Last Chance Discussion
Becoming Better The Last Chance Discussion
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
heartandsoulofchange.com June 12, 2015
pcoms.com 18
100
My Data
405060708090P
ercent reaching
%
98%
0102030
1 2 3 4 5 6 7
target
75%
Failing SuccessfullyFailing Successfully
Change of Therapist
heartandsoulofchange.com June 12, 2015
pcoms.com 19
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.
heartandsoulofchange.com June 12, 2015
pcoms.com 20
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
heartandsoulofchange.com June 12, 2015
pcoms.com 21
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.
heartandsoulofchange.com June 12, 2015
pcoms.com 22
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.