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7/28/2011
1
Jacqueline Sparks, Ph.D.Associate Professor
University of Rhode Island
TEACHING OUTCOME-INFORMED PRACTICE
Integrating CDOI &University Graduate Training [email protected]
Colleagues
Department of Human Development & Family Department of Human Development & Family Studies – University of Rhode Island
Couple & Family Therapy Program
Jerome Adams Tiffani Kisler Jacqueline Sparks Dale Blumen
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Our Program
Students accrue 500 direct client contact
S d i 1 l l i h l
AAMFT Accredited
Students intern 1 year at local agencies, schools, residential treatment, or hospital
Students carry a caseload at on-campus clinic
2-year, full-time, 60 credits
Supervision provided by approved supervisors
Where We’re Headed
Identifying and connecting with stakeholder interests
Cultivating allies
First steps
Integration (curricula, clinical training & supervision, evaluation)
Tools
Results
Maintaining & Building
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Stakeholders
Program (faculty & students)Program (faculty & students)
Clients (served by our clinic)
Department & University
Communityy
Professional Field
Program Interests
Train effective practitioners
Create a unifying training model that conforms with core program philosophy
Provide optimum service to clients
Provide practice-based research opportunities
Offer new options for community network providers Offer new options for community network providers
Develop a competitive profile as a forward leaning, innovative program
Align with University and the field’s interests in outcome-based learning.
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Train Effective Practitioners
Clients have largely been overlooked as teachers
Th f l h h Therapists performing poorly can improve when they routinely integrate client feedback into their work
A feedback system would give us a field-tested method for helping trainees with poorer outcomes improve.
CDOI Fit with Program Philosophy
Collaborative & Strengths-based – Teaching students to routinely ask for and respond to client feedback embodies routinely ask for and respond to client feedback embodies core values related to collaboration and a strengths focus
Integrative – CDOI as a centerpiece for student integration of diverse treatment models
Commitment to diversity –With client voices guiding With client voices guiding clinical work, trainees could learn from and better assist persons whose social and cultural locations differed from their own
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Improve Clinic Services
Drop outs are a significant problem in the delivery of mental health services, averaging at least 47% (Wierzbicki & Pekarik, 1993)
Training clinics have more premature terminations and fewer successful outcomes than in other outpatient settings (Callahan et al., 2009)
Our clinic serves financially disadvantaged clients –
i i f li f provision of quality care of particular concern
CDOI could serve as a vehicle for improving the effectiveness of our clinic services
Practice-Based Research Opportunities
MFT research and practice historically have been disconnected if not iewed as in opposition disconnected, if not viewed as in opposition
Clinics operate “in the dark,” and students absorb the message that continuous assessment of services is not important
CDOI would instill in students a sense of the ethics and utility of a client – service system loop
CDOI would supplement our ongoing research and client satisfaction protocols
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Creating a Competitive Profile
Interested in
To the University of Rhode Island Couple and Family Therapy
Program Information Interview
attracting and recruiting top students from across the country and abroad.
CDOI offered an i
WELCOME
opportunity to showcase our program as unique and exceptional.
Community Interests
Larger systems of care serving children and families in our area moving to measurably identify treatment success or failure
Desire for University ll b i i collaborative service
partnerships that introduce innovative, effective, and efficient new models
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Department & University Interests
Desire for exceptional, empirically-based scholarship
Interest in objective, outcome-based models of evaluating student learning
Interest in meaningful service and connection with local Interest in meaningful service and connection with local communities, state agencies, and statewide initiatives
Emphasis on attracting a diverse student body and faculty and offering a diversity-infused curriculum
Interest in global engagement and partnership
Interests of the Field
Calls for the provision of “safe, effective, patient-centered, ti l ffi i t d it bl ” h lth i l di timely, efficient, and equitable” health care, including mental health (Committee on Quality of Health Care in America, 2001, pp. 7-8; President’s New Freedom Commission on Mental Health, 2003)
Mental and behavioral health organizations attempt to define effective, safe care (e.g., see APA Presidential Task define effective, safe care (e.g., see APA Presidential Task Force on Evidence-Based Practice, 2006)
The AAMFT defines core competencies and calls for shift from input-oriented to outcome-based education.
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Fit with Core Competencies
Domain 4: Therapeutic Interventions Match treatment modalities and techniques to clients’ needs Match treatment modalities and techniques to clients needs,
goals, and values. 4.3.1 Facilitate clients developing and integrating solutions to
problems. 4.3.16 Modify interventions that are not working to better fit
treatment goals. 4.3.10 Evaluate treatment outcomes as treatment progresses. 4.4.3 Evaluate treatment outcomes as treatment progresses. 4.4.3 Evaluate clients’ reactions or responses to interventions.
4.4.4 Evaluate clients’ outcomes for the need to continue, refer, or
terminate therapy. 4.4.5
Input-Oriented Clinical Training
Training in model h itechniques
Emphasis on use of EBT without client input
Skills training
Emphasis on accrued Emphasis on accrued clinical hours
Intensive supervision (often self-report)
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CompetenceCompetence====
EffectivenessEffectiveness
Input to Outcome-Based Training
Not Related to OutcomeNot Related to Outcome Related to OutcomeRelated to Outcome
Skills training
Supervision
Hours of experience
Feedback protocols for improving counselor efficacy
Reese, R. J., Usher, E. L., Bowman, D., Norsworthy, L., Halstead, J., Rowlands, S. et al. (2009). Using client feedback in psychotherapy training: An analysis of its influence on supervision and counselor self-efficacy. Training and Education in Professional Psychology, 3(3), 157-168.Whorthen, V. E.. & Lambert, M. J. (2007). Outcome oriented supervision: Advantages of adding systematic client tracking to supportive consultations. Counseling and Psychotherapy Research, 7(1), 48-53.
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Recruiting the Team
Once CDOI-based training is connected to the varying interests and the empirical literature, support follows. . .
Cultivate the CDOI Garden
E l i th t CDOI d t Explain that CDOI does not replace a preferred view or treatment approach
Work collaboratively to create a team that has a shared mission f i l t ti of implementation
Identify projects and responsibilities
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Choose Measures
W h (ORS) (CORS) (SRS) We chose (ORS) (CORS) (SRS) (CSRS)
Met standards of practicality for everyday clinical use without sacrificing validity and
li bilitreliability.
Brevity and face validity of the instruments facilitate administration
Choose Tracking System
We are using ASIST
Data is entered into ASIST (either in the room on a laptop or after the session)
ASIST automatically calculates and graphically depicts a trajectory of change and target benchmark
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Integration
Begin at applicant interview
S di f
How URI CFT Training Is Unique
Summer reading for incoming students
Students systematically gather formal feedback from clients at each session to guide treatment (Outcome Management [OM]).
Duncan, B. (2011). What therapists want: It’s Duncan, B. (2011). What therapists want: It’s certainly not money or fame. certainly not money or fame. Psychotherapy Psychotherapy Networker, May/June, 40Networker, May/June, 40--43, 47, 62.43, 47, 62.Duncan, B. (2011). Opening a path: From what is Duncan, B. (2011). Opening a path: From what is to what can be. to what can be. Psychotherapy Networker, Psychotherapy Networker, May/June 46May/June 46--4747
Pre-Practicum
The Heroic Clients, Heroic Agencies Manual serves as a basic text
Students receive hands on training in CDOI
Students role play introducing, p y g,integrating the measures and being informed by client feedback
Available for download at Available for download at www.heartandsoulofchange.com www.heartandsoulofchange.com
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Theory Course
Second course focuses on postmodern to present
H i Cli t i i t d d i th d h lf f th Heroic Client is incorporated during the second half of the second course
Students learn current evidence for feedback, common factors, and understand evidence based practice as currently defined by APA
Learn and evaluate the principles and application of practice-based evidence with an emphasis on current research and debates in the field and as an integrative theory in family therapy.
Practicum
CDOI provides a ready- made structure
S d l h f ll i l Students learn how to respectfully, yet persistently, request and respond to client feedback
Students learn to identify problems and address them before clients drop out
Clients come to trust not only their therapist’s only their therapist s desire to learn their views, but the significance of their own perspectives to treatment success.
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Supervision
Therapists are required to bring graphs, measures, d ASIST i l f ll i i
Supervisors use information from the measures to structure the supervisory
and ASIST signals for all supervision
p yconversation, including requests for specific video data
Supervision Decision Points
Supervisors can prioritize at- Supervisors can prioritize atrisk cases that need immediate attention
Helps to generate conversations about different approaches that may better approaches that may better fit a given client’s preferences and expectations.
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Identifying and Amplifying Change
Visual trajectories help trainees, supervisors, and clients demarcate change and plan for termination
Supervisors have a tool for privileging the client’s unique lived experience over theory
Shorter lengths of stay with fewer cases extending beyond 4 months where no measurable change has occurred.
Including the Client in Supervision
Supervisor/supervisee conversations are now more intimately connected to client experiences
Clients’ voices become the central focus of supervision conversations and planning.
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Live Supervision
Live supervision using one-p gway mirror gives supervisor real time information
Supervisor can make more targeted suggestions for in-session process and homework
Live supervision using CDOI Live supervision using CDOI has resulted in more productive supervisory focus and more efficient and successful sessions
Evaluation
Students conduct a self-assessment at the end of each semester of practicumsemester of practicum
The Student Clinical Self-Assessment Report requires students to analyze their outcome data for % of clients reaching benchmark, average alliance score, length of stay, and % of cases defined as drop-out
From this assessment and supervisor From this assessment and supervisor evaluation, students set goals for their next practicum
Evaluations are directly connected to outcomes identified by clients.
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Evaluation
Student caseload ratings of outcome and alliance h ld b f di ishould not be sources of grading or promotion
Grading reflects students’ engagement in the process and willingness to learn from clients
Our mantra is: “There is no There is no negative feedback, only negative responses to it.”
Expanding the Learning
Cultivate knowledge and appreciation of CDOI at community internship sites
Connect CDOI to site needs related to outcome evaluation
Invite site staff and supervisors to
community internship sites Encourage students to conduct CDOI-based research at
sites
Invite site staff and supervisors to trainings and roundtable discussions
Introduce the goal of requiring students to track all outcomes as part of their training and evaluation
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School-based Site Research
ORS/CORS assessments of 72 students, aged 6-18
f Students referred to Ledyard Youth Services by guidance counselors, school psychologists, teachers, and parents between 2009 and 2011
Anger, poor communication with family members, interpersonal difficulties with peers, bullying, depression, poor academic performance,
and substance abuse
ORS, 38 youth; CORS 34 children
Results – Ledyard Youth Services
Youth and children experienced significant gains in pre-post analysis (average mean increased 7 3 points pre post analysis (average mean increased 7.3 points ORS and 5.0 on CORS)
At or above clinical cutoff scores for ORS increased from 39.5% to 81.6%; CORS, 50% to 79.4%
Combined ORS and CORS sample 93% p %reached benchmark
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Additional Sites Adopting
Large multiple service agency for at-g p g yrisk children and families integrating CDOI throughout
Regional modified wrap-around program instituting CDOI into service delivery in the community
Office-based community mental health agency and residential treatment program open to training; several CDOI practitioners on staff and interning
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Client Feedback on ORS Use
Sample: 9 adults and 2 16-year old boys
1 family, 3 individuals, 2 unmarried couples
Caucasian, African American, mixed race
7, somewhat helpful; 2 extremely helpful; , p ; y p ;1, unhelpful; 1, neither helpful nor unhelpful
81.8% somewhat or extremely helpful
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Qualitative Responses ORS
Extremely helpful: “it gave a good basis of how h k h d d h I f l b ” d “ the week had gone and how I felt about it,” and “a tool for better family living”
Somewhat helpful: “feeling good,” “fairly and consistently positive,” “good visual tool,” “good jumping off point for the session,” “I don’t always recall where we are or how we progressed”
Neither helpful nor unhelpful: “it was nice to learn about my personal progress but charting us against what is ‘normal’ feels counter-intuitive”
Client Feedback on SRS
6 of 11 responses (54.6%), somewhat helpful
f f 3 of 11, extremely helpful
1, unhelpful; 1, neither helpful nor unhelpful
81.9%, somewhat or extremely helpful
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Qualitative Responses SRS
Somewhat or Extremely Helpful: Importance of letting the therapist know how the are feeling letting the therapist know how they are feeling about the session; “made me consider the things we went over in a bit more depth”
Neither Helpful nor Unhelpful: “trying to rate on the spot gave me no time to reflect on the session. F l ti d t ith For example, sometimes one does not agree with what a therapist might say or advice until on can process it”
3 and 6-Month Follow-Up
69 clients contacted 3 and/or 6 months post therapy
25 l 44 f l d 5 67 LOS 9 07 25 male, 44 female; aged 5 to 67; mean LOS 9.07 sessions
69 completed ORS last session; 36, 3 months; 38, 6 months
ORS was administered telephonically
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3 and 6-Month Follow-up (n = 69)
ORS1: 22.33 ORS2 31.00 ORS3 31.01 ORS4 30.12
Clinical Outcomes (208 cases)
Therapist n = 31
4 ½ -year period
Av. # of sessions: 7
Av. LOS 3 mos.
% of clients reaching benchmark 71%
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Student Feedback
CDOI : Gives a conceptual and practical framework to t bli h l f t d fidestablish early comfort and confidence
Provides practical guidance for structuring the session
Provides a format for clients to guide treatment
Provides an incentive for expanding beyond one’s comfort zone and for learning new skillsone s comfort zone and for learning new skills
Helps to minimize guesswork regarding whether progress is being made or a case may be at risk
Provides a format for learning about children’s views
Expanding One’s Comfort Zone
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Counselor Education at a Crossroad
I found the paper compelling (JMFT Associate Ed.)
I believe this is a watershed article that will have a lasting impact on how supervision is done in the future—both in mft and in other mental health professions. (JMFT Reviewer)
The authors have done a stellar job on an important piece that I believe will have a lasting impact on the field (JMFT Reviewer)
Sparks, J. A., Kisler, T. A., Adams, J. F., & Blumen, D. G. (in press). Teaching accountability: Using client feedback to train family therapists.Journal of Marital and Family Therapy.