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Handbook of Psychotherapy Integration, Second Edition Part 3 pps

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Outcome-Informed Clinical Work 95 to have a negative or null outcome (Miller, other oversight procedures has exploded in re- cent years, consuming an ever-increasing amount Duncan, Brown, Sorrell, & Chalk, in press). In that same study, further improvement in of time and resources. Where a single HCFA 1500 form once sufficed, clinicians now have to outcomes was realized when decisions about whether to change or maintain a particular contend with a “paper curtain” made up of pre- treatment authorization, intake interviews, treat-pairing of client and therapist were informed by formal client feedback. Logically, clients ment plans, and ongoing quality assurance re- views—procedures that add an estimated $200 to that were already improving did significantly better when encouraged to continue meeting $500 to the cost of each case (Johnson & Shaha, 1997). The addition of all this paperwork presum- with (75th percentile) rather than change ther- apists (25th percentile). ably is based on the premise that controlling treatment process will enhance outcomes. On a positive note, two large behavioral health care or- ganizations have recently eliminated virtually all paperwork and automated the treatment authori- CASE EXAMPLE zation process based on the submission of out- come and process tools (Hubble & Miller, 2004).Robyn was a 35-year-old, self-described “agora- phobic” brought to treatment by her partner Returning to the case, the therapist met Robyn and Gwen in the waiting area. Following somebecause she was too frightened to come to the session alone. Once an outgoing and energetic brief introductions, the three moved to the con- sulting room where the therapist began scoringperson making steady progress up the career lad- der, Robyn had during the last several years grown the outcome measure. progressively more anxious and fearful. “I’ve al- T HERAPIST : You remember that I told you on the ways been a nervous kind of person,” she said phone that we are dedicated to helping our cli- during her first visit, “Now, I can hardly get out ents achieve the outcome they desire from treat- of my house.” She added that she had been to ment? see a couple of therapists and tried several medi- R OBYN : Yes. cations. “It’s not like these things haven’t helped,” T: And that the research indicates that if I’m go- she said, “it’s just that it never goes away, com- ing to be helpful to you, we should see signs of pletely. Last year, I spent a couple of days in the that sooner rather than later? hospital.” In a brief telephone call prior to the first ses- R: Uh huh. sion, the philosophy of our outcome-informed T: Now, that doesn’t mean that the minute you approach to clinical practice had been described start feeling better, I’m going to say “hasta la to Robyn and her partner, Gwen. As requested, vista, baby” the two arrived a few minutes early for the ap- R AND G WEN : (laughing). Uh huh. pointment, completing the necessary intake and T: It just means your feedback is essential. It will consent forms, as well as the outcome measure tell us if our work together is on track, or whether in the reception area while waiting to meet the we need to change something about the treat- therapist. The intake forms requested basic infor- ment, or, in the event that I’m not helpful, when mation required by the state in which services we need to consider referring you to someone or were offered. The outcome measure used was the someplace else in order to help you get what you ORS (Miller & Duncan, 2000b). In this practice, want. the entire process takes about 5 minutes to com- plete. R: (nodds). One attractive feature of an outcome-informed T: Does that make sense to you? approach is an immediate decrease in the pro- R: Yes. cess-oriented paperwork and external manage- ment schemes that govern modern clinical prac- Once completed, scores from the ORS were entered into a simple computer program runningtice. The number of forms, authorizations, and 96 Integrative Psychotherapy Models on a PDA. The results were then discussed with in the same way as the first one (pointing at the individual items) with low marks to the left tothe couple. high to the right rating in these different areas T: Let me show you what these look like. Um, basically this just kind of gives us a snapshot of how things are overall. R: (leaning forward). Uh huh. R: Uh huh. T: It kind of takes the temperature of the visit, T: . . . this graph tells us how things are overall how we worked today ifitfelt right work- in your life. And, uh, if a score falls below this ing on what you wanted to work on, feeling un- dotted line derstood R: Uh huh. R: All right, okay (taking the measure, complet- ing it, and then handing it back to the therapist). T: Then it means that the scores are more like people who are in therapy and who are saying (A brief moment of silence while the therapist that there are some things they’d like to change scores the instrument) or feel better about T: Okay yousee, just like with the first one, R: Uh huh. I put my little metric ruler on these lines and measure and from your marks that youT: . . . and if it goes above this dotted line, that indicates more the person saying, you know, “I’m placed, the total score is 38 and that means that you felt like things were okay today doing pretty well right now.” R: Uh huh. R: Uh huh. T: And you can see that overall it seems like T: That we were on the right track talking you’re saying you’re feeling like there are parts of about what you wanted to talk about your life you’d like to change, feel better about R: Yes, definitely. T: Good. R: Yes, definitely. R: I felt very comfortable. T: (setting the graph aside and returning to the T: Great I’mglad to hear that atthesame ORS form). Now, it looks like interpersonally, time, I want you to know that you can tell me if things are pretty good things don’t go well R: Uh huh. I don’t know how I would have made R: Okay. it without Gwen. She’s my rock T: I can take it T: Okay, great. Now, individually and socially, youcansee R: Oh, I’d tell you R AND G: (leaning forward). T: You would, eh? T: . . . that, uh, here you score lower R: (laughing). Yeah just ask Gwen Both Robyn and Gwen confirmed the pres- In consultation with Robyn, an appointment ence of significant impairment in individual and was scheduled for the following week. In that ses- social functioning by citing examples from their sion and the handful of visits that followed, the daily life together. At this point in the visit, Robyn therapist worked with Robyn alone and, on a indicated that she was feeling comfortable with couple of occasions, with her partner present, the process. Gwen exited the room as the pair to develop and implement a plan for dealing had planned beforehand and the session contin- with her anxiety. Recall that from an outcome- ued for another 40 minutes. informed perspective, the particulars of the plan As the end of the hour approached, Robyn are not important. Rather, the client’s early sub- was asked to complete the SRS. jective experience of the alliance and improve- ment whatever the process.T: This is the last piece asImentioned, your feedback about the work we’re doing is very im- Though Robyn’s fear was palpable during the visits, she nonetheless gave the therapy the high-portant to me andthis little scale itworks Outcome-Informed Clinical Work 97 est ratings on the SRS. Unfortunately, her scores clinical work of Anderson (1991) and is often use- ful for generating possibilities and alternatives. Ason the outcome measure evinced little evidence of improvement. By the fourth session, the com- Friedman and Fanger (1991, p. 252) summarize: puterized feedback system was warning that the The views offered are not meant to be judg- therapy with Robyn was “at risk” for a negative ments, diagnostic formulations, or interpreta- or null outcome. tions. No attempt is made to arrive at a team The warning led the therapist and Robyn to consensus or even to come to any agreement. review her responses to each item on the SRS at Comments are shared within a positive frame- the end of the fourth visit. Such reviews are not work and are presented as tentative offerings. only helpful in ensuring that the treatment con- tains the elements necessary for a successful out- As frequently happens, Robyn found one team member’s ideas particularly intriguing. Here again,come but also provide another opportunity for identifying and dealing with problems in the ther- the particular idea offered is unimportant. Rather, client engagement is the issue. When the sug-apeutic relationship that were either missed or went unreported. In this case, however, nothing gested change in approach had not resulted in any measurable improvement by the eighth visit,new emerged. Indeed, Robyn indicated that her high marks matched her experience of the visits. the computerized feedback system indicated that a change of therapists was probably warranted. T: I’m just wanting to check in with you Indeed, given the norms for this particular setting, R: Uhhuh the system indicated that there was precious little chance that this relationship would result in suc- T: . . . and make sure that we’re on the right track cess. Clients vary in their response to an open and R: Yeah uhhuh okay frank discussion regarding a lack of progress in T: And, you know, looking back over the times treatment. Some terminate prior to identifying an we’ve met at your marks on the scale alternative, while others ask for or accept a refer- about the work we’re doing the scores indi- ral to another therapist or treatment setting. If the cate that you are feeling, you know, comfortable client chooses, the therapist may continue in a with the approach we’re taking supportive fashion until other arrangements can R: Absolutely be made. Rarely, however, is there justification for continuing to work therapeutically with cli- T: That it’s a good fit for you ents who have not achieved reliable change in a R: Yes period typical for the majority of cases seen by a T: I just want to sort of check in with you and particular therapist or treatment agency. In es- ask, uh, if there’s anything, do you feel or sence, clinical outcome must hold therapeutic have you felt between our visits even on oc- process “on a leash.” casion that something is missing In the discussions with the therapist, Robyn R: Hmm. shared her desire for a more intensive treatment approach. She mentioned having read about an T: That I’m not quite “getting it.” out-of-state residential treatment center that spe- R: Yeah (shaking head from left to right). No cialized in her particular problem. When her in- . . . I’ve really felt like we’re doing that surance company refused to cover the cost of the this is good this is right, the right thing for me. treatment, Robyn and her partner put their only car up for sale to cover the expense. In an inter-In spite of the process being “right,” both the therapist and Robyn were concerned about the esting twist, Robyn’s parents, from whom she had been estranged for several years, agreed to coverlack of any measurable progress. Knowing that more of the same approach could only lead to the cost of the treatment when they learned she was selling her car.more of the same results, the two agreed to orga- nize a reflecting team for a brainstorm session. Six weeks later, Robyn contacted the therapist. She reported having made significant progressBriefly, this process is based on the pioneering 98 Integrative Psychotherapy Models during her stay, as well as reconciling with her thus far, results in significant improvements in outcome. family. Prior to concluding the call, she asked whether it would be possible to schedule one Such results notwithstanding, more work re- mains to be done. As noted previously, re- more visit. When asked why, she replied, “I’d want to take that ORS one more time!” Needless search to date has focused largely on mental health services delivered to adults in outpatient to say, the scores confirmed her verbal report. In effect, the therapist had managed to “fail” suc- settings or via the telephone. Currently, work is being done to determine the extent to which cessfully. the measures and results generalize to other treatment populations and settings. For exam- ple, studies on services delivered in group, via case management, with child- and family- related problems, and in residential treatment FUTURE DIRECTIONS Health care policy has undergone tremendous settings are underway. At the same time, efforts are being made to expand and enhance thechange during the last two decades. Among the differences is an increasing emphasis on out- technological interface. Given the importance of the client’s view of and engagement in thecome that is not specific to any particular pro- fessional discipline (e.g., mental health vs. feedback process—an aspect missing in the re- search thus far—the feasibility and impact ofmedicine) or type of payment system (e.g., managed care vs. indemnity-type insurance or Web and e-mail based data-entry and retrieval are being studied.out-of-pocket payment). Rather, it is part of a worldwide trend (Andrews, 1995; Humphreys, Though we are skeptical, several projects are underway to determine whether there are1996; Lambert, Okiishi, Finch, & Johnson, 1998; Sanderson, Riley, & Eshun, 1997). The any consistent qualities of reliably superior therapists and treatment settings. Should anyshift toward outcome is so significant that Brown et al. (1999, p. 393) argued, “In the be found, subsequent studies would examine the impact of transferring the findings to oth-emerging environment, the outcome of the ser- vice rather than the service itself is the product ers. Presently, the weak relationship between professional training and outcome in psycho-that providers have to market and sell. Those unable to systematically evaluate the outcome therapy raises serious questions about profes- sional specialization, training and certification,of treatment will have nothing to sell to pur- chasers of health care services.” reimbursement for clinical services, and, above all, the public welfare (Berman & Norton,Currently, the most popular approach for addressing calls for accountable treatment 1985; Christensen & Jacobsen, 1994; Clement, 1994; Garb, 1989, Hattie, Sharpley, & Rogers,practice has been to focus on organizing and systematizing therapeutic process, molding the 1984; Lambert et al., 2003; Lambert & Ogles, 2004; Stein & Lambert, 1984).practice of psychotherapy into the “medical model.” By contrast, the approach described in Of course, we believe that becoming out- come-informed would go a long way towardthis chapter involves shifting away from process and toward outcome. Evidence for this per- correcting these problems, at the same time of- fering the first “real-time” protection to con-spective dates back 18 years, beginning with the pioneering work of Howard, Kopte, Krause, sumers and payers. Instead of empirically sup- ported therapies, consumers would have access& Orlinsky (1986) and extending forward to Lambert, Shapiro, & Bergin (1996, 1998, to empirically validated therapists. Rather than evidence-based practice, therapists would tailor2003), Johnson & Shaha (1996, 1997; Johnson, 1995), and our own studies (Miller, Duncan, their work to the individual client via practice- based evidence. With that end in mind, we areBrown, Sorrell, & Chalk, in press). The ap- proach is simple, straightforward, unifies the spending a significant amount of time and ef- fort studying how best to communicate the ad-field around the common goal of change, and, unlike the process-oriented efforts employed vantages of an outcome-informed perspective Outcome-Informed Clinical Work 99 to therapists, third-party payers, and certifying and behavior change (2nd ed., pp. 217–270). New York: Wiley. bodies. As Lambert et al. (2003) point out, “those advocating the use of empirically sup- Berman, J. S., & Norton, N. C. (1985). Does profes- sional training make a therapist more effective? ported psychotherapies do so on the basis of much smaller treatment effects” (p. 296). Psychological Bulletin, 98, 401–406. Bordin, E. S. (1979). The generalizability of the psy- choanalytic concept of the working alliance. Psychotherapy, 16, 252–260. References Brown, J., Dreis, S., & Nace, D. K. (1999). 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Goldfried (Eds.), Handbook of psychotherapy integration (pp 231 – 2 63) New York: Basic Books Lazarus, A A (19 93) Tailoring the therapeutic relationship, or being an authentic chameleon Psychotherapy, 30 , 404–407 Lazarus, A A (1995) Different types of eclecticism and integration: Let’s be aware of the dangers Journal of Psychotherapy Integration, 5, 27 39 Lazarus, A A (1996) The utility and futility of combining... 19 93) In 19 83, the Society for the Exploration of Psychotherapy Integration (SEPI) was founded, held annual international conferences, and launched the Journal of Psychotherapy Integration It is my view that the much-needed emphasis on eclecticism and integration has served ´ a useful purpose but that it is now passe The narrow and self-limiting consequences of adhering to one particular school of. .. predictive of psychotherapy outcome Psychotherapy Bulletin, 26, 26–27 Herman, S M (1992) A demonstration of the validity of the Multimodal Structural Profile Inventory through a correlation with the Vocational Preference Inventory Psychotherapy in Private Practice, 11, 71–80 Herman, S M (1994) The diagnostic utility of the Multimodal Structural Profile Psychotherapy in Private Practice, 13, 55–62 Herman,... people, and that the “study of the effects of psychotherapy, therefore, is always the study of the effectiveness of techniques” (p 33 ) Thus, I recommended that we cull effective techniques from many orientations without subscribing to the theories that spawned them I argued that to combine different theories in the hope of creating more robust methods would only furnish a ´ melange of diverse and incompatible... Studies, 1, 39 –48 120 Integrative Psychotherapy Models Lazarus, A A., & Beutler, L E (19 93) On technical eclecticism Journal of Counseling & Development, 71, 38 1 38 5 Lazarus, A A., Beutler, L E., & Norcross, J C (1992) The future of technical eclecticism Psychotherapy, 29, 11–20 Lazarus, A A., & Lazarus, C N (1987) Commentary: Reactions from a multimodal Perspective In J C Norcross (Ed.), Casebook of eclectic... dissertation, Department of Psychology, University of Glasgow Wilson, G T (1998) Manual-based treatment and clinical practice Clinical Psychology: Science and Practice, 5, 36 3 37 5 Wolpe, J., & Lazarus, A A (1966) Behavior therapy techniques Oxford: Pergamon 6 Systematic Treatment Selection and Prescriptive Psychotherapy: An Integrative Eclectic Approach LARRY E BEUTLER, ANDRES J CONSOLI, AND GEOFFREY LANE... assessment of compliance with these optimal principles requires direct observation and measurement of the treatment processes The most basic of principle resonates with the old adage that an informed consumer makes for a better one In other words, the likelihood of positive psychotherapy outcomes is significantly increased when patients are properly informed of how to make best use of the services offered... Social foundations of thought and action: A social cognitive theory Englewood Cliffs, NJ: Prentice Hall Davison, G C., & Lazarus, A A (1994) Clinical innovation and evaluation: Integrating practice with inquiry Clinical Psychology: Science and Practice, 1, 157–168 Fay, A., & Lazarus, A A (19 93) On necessity and sufficiency in psychotherapy Psychotherapy in Private Practice, 12, 33 39 Herman, S M (1991)... training (e.g., the use of coping imagery and the selection of mental pictures that evoked profound feelings of serenity) A Structural Profile Inventory (SPI) has been developed and tested This 35 -item survey provides a quantitative rating of the extent to which clients favor specific BASIC I.D areas The instrument measures action-oriented proclivities (Behavior), the degree of emotionality (Affect),... that is predictive of treatment outcome (Beutler & Malik, 2002; Carson, 1997) From researchers have come an appreciation of the power of controlled observations and of the relative advantages of both efficacy and effectiveness research From research findings, we have also become acutely aware of the strangely contrasting and seemingly contradictory views about the contributors to psychotherapy benefit . professional experience. Psychological Bulletin, 105, 38 7 39 2.A. E. Bergin (Eds), Handbook of psychotherapy 100 Integrative Psychotherapy Models Gurman, A. (1977). The patient’s perceptions of. effectiveness of profes- sional and paraprofessional helpers. Psychologi- in psych otherapy. Psychotherapy, 35 , 225– 236 . Johnson, L. D., & Shaha , S. H. (1997, July). Upgrad-cal Bulletin, 95, 534 –541. Horvath,. outcome.seling Psychology, 38 , 139 –149. Horvath, A. O. (2001). The alliance. Psychotherapy, Clinical Psychology Review, 9, 469–485. Lambert, M. J. (1992). Implications of outcome re -38 , 36 5 37 2. Horvath,

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