Monitoring in family therapy How to stay loyal to our dialogical values ?

1. Monitoring in family therapyHow tostayloyaltoourdialogicalvalues? Karine Van Tricht, Peter Rober & RolfSundet 2nd Congress of the Open Network forDialogicalPractices 7-9 March 2013 Leuven, Belgium

2. Measure of process and outcome as conversational tools: Pathways to a dialogical oriented practice of service user and therapist collaboration. Rolf Sundet Leuven, 2013 rosundet@online.no University College of Buskerud, Institute for Research in Mental Health and Substance Abuse & The Ambulant Family Section, Dept of Mental Health for Children and Adolescents, Hospital of Drammen, VestreViken HF.

3. Mental Health Care anno 2013 • Neoliberal society – Market economy • Economic product • Profitability • Money • Results • Social benefit • Psychotherapy • Evidencebased • Effective • Efficient • ‘To measure is to know’ atmosphere • Quality Control Systems

4. FromEvidenceBasedPracticetoPracticeBasedEvidence • RCT’s & Psychotherapy • Specificity & complexity • Generalizability? • Externalvalidity? • Creativity? • RCT’s & Family Therapy = trouble in paradise • What is the diagnosis? • Complexityandspecificity of treatment • Who/what is responsiblefor change?

5. Monitoring: bridging the gap between research andpractice • Terminology • Outcome management • Routine Outcome Monitoring • Routine OutcomeMeasurement • Feedback Orientedtherapy • Client DirectedOutcomeInformedTherapy • Tracking • Monitoring • ROMMEN • QITTEN

6. Evidence • Outcomeimprovement • Duncan & Sparks, 2009; 2010 • Reese et al., 2010 • Anker, Duncan & Sparks, 2009 • Duncan & Miller, 2000 • Drop-out prevention & betterdose/effect ratio • Lambert, 2007; 2010 • Experiencedas useful and helpful • Anker et al., 2011 • Leadingto a betterworkingalliance • Sundet 2010; 2011; 2012

7. Monitoring as a way of workingtogether Van Tricht & Rober

8. Sources of inspiration (1) The room of the therapist as a dialogicalspacein which a multitude of stories, opinions, emotionsandperspectivescometogether Van Tricht, Van den Broeck, Rober, 2011; Rober 2012

9. Sources of inspiration (2) • QIT online (QualityImprovement in Therapy) Stinckens, Smits, Rober & Claes, 2012

10. A qualitative study of a locally developed family based practicewithin Mental Health for Children and Adolescents Conclusions: Two measures, the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS): • They function as intended, that is; as tools of feedback. • A surplus: They function as conversational tools, that is; they give rise and opportunity to conservational types and processes

14. Repairinganallianceburstbymeans of discussing feedback

15. Clinicalconclusion The ORS and the SRS do not give answers, they are opportunities for questions

16. The family perspective: The function of ORS & SRS as conversational tools

18. The TherapistPerspective: The Functionof ORS and SRS as conversationaltools

20. ConceptualFramework QIT Family Van Tricht & Rober

21. Specificity of integrating monitoring in Family Therapy • Instrumental level • Adult & childversions • Outcome & process • Implementational level • Clearintroduction • In session: Apart / together • Home work: Apart / together • On paper or electronic • Dialogical level • Open, curious, interested and non-judgmental T attitude • Feedbackloops: how, what, when • Enactment

22. Measurements of QIT Family • [Informed Consent (Van Tricht & Rober, 2013)] • Concerns Questionnaire (Van Tricht & Rober, 2013) • SCORE-15 (Fay e.a., 2012; Stratton, subm. in JFT) • OQ-45 (Lambert e.a., 1996) • YOQ-30.2 (Burlingame & Lambert, 2001) • ORS (Duncan & Miller, 2000) • SRS (Duncan & Miller, 2000) • (Y)CORS (Duncan, Miller & Sparks, 2003) • (Y)CSRS (Duncan, Miller & Sparks, 2003) • TSS(Kokotovic& Tracey, 1990; Tracey, 1989; Hafkenscheid, 2012) • IMI(Kiesler, 1996; Hafkenscheid, 2012)

23. Van Tricht & Rober

24. Feedback CULTURE In the relationship between service user and therapist, the therapist perspective must be transparent and the service users perspective is given priority, especially in situations of no change or detrimental development In the relationship between management and therapists the perspective of managers must be transparent and the therapist perspective must be given priority in each actual case. The function of feedback is dependent upon allowing the therapists clinical autonomy in order to respond in a tailored manner to the feedback from the service users. These measures are in danger of being ruined as feedback and conversational tools if they are included in a culture of competition and control

25. Thank you!

26. Alliances in CoupleTherapy • How todefine the alliance in systemictherapies? • Dyadic relations / additional information? • Clinicalrelevancewhenthere’ssomuchconfusion? • Overall conclusion: • Positivecorrelationbetweenworkingalliance and successfuloutcome • Addingone more person adds multiple relationships Muran & Barber, 2010

27. Alliances in CoupleTherapy • Individual model of the alliance + relationaldynamics(Couple Alliance Scale, Pinsof& Catherall, 1984) • Alliancesbetweeneachclientand the therapist • Directself-reportedalliance • Inferredalliance (guesses of the qual. & strenght of the partners’ rel. T) • Alliance between ‘clients-as-a-couple’ and the therapist • Relational(im)balances • split alliances/siding/movingtoward equilibrium Muran & Barber, 2010

28. “An emergingquality of collaboration in relationto the necessaryaccomplishments, arisingfrom a web of interactingrelationaldynamics” Gender Gender Enactment Motivation Power Gender Muran & Barber, 2010

29. A Dialogically ORIENTED PRACTICE • including the voice, perspective, idea of the other, that is; difference is included in the dialogical. • to respond to the other and be responded by the other. • to be embodied and embedded in social practices, that is; working with and in emotional transport and relational action

30. The practice • The use of conversational tools and the weight on dialogue gives rise to a practice where reflection and meaning making are intertwined with emotional and experiential participation of the therapist • The centrality of collaboration

31. Collaboration • Collaboration is characterized by; • Mutualism (turn-taking, jointly responding to the other’s response, dialogue, conversation) • Common goal • Putting difference to work

32. Familybasedpractice

33. Publications Sundet, R. (2010). Therapeutic collaboration and formalized feedback: Using perspectives from Vygotsky and Bakhtin to shed light on practices in a family therapy unit, Clinical Child Psychology and Psychiatry, 15(1), 81-95 Sundet, R. (2011). Collaboration: Family and therapists perspectives of helpful therapy. Journal of Marital and Family Therapy, 37(2), 236-249 Sundet, R. (2012). Therapist perspectives on the use of feedback on process and outcome: Patient focused research in practice. Canadian Psychology, 53(2), 122-130 Sundet, R (2012).  Patient focused research supported practices in an intensive family therapy unit: What happens? Journal of Family Therapy, (Accepted for publication). Sundet, R. (2012).  Postmodern-oriented practices and implementation of patient-focused research: Possibilities and hazards. Australian and New Zealand Journal of Family Therapy (In review).