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Strengths-Based Therapy Bob Bertolino , Ph.D. Associate Professor, Maryville University Sr. Clinical Advisor, Youth In Need, Inc. Sr. Associate, International Center for Clinical Excellence. Tidbits.

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  1. Strengths-Based TherapyBob Bertolino, Ph.D.Associate Professor, Maryville University Sr. Clinical Advisor, Youth In Need, Inc. Sr. Associate, International Center for Clinical Excellence

  2. Tidbits • A few PowerPoint slides are absent from your handouts. For any missing slides, please go to: www.bobbertolino.com • Contact: bertolinob@cs.com; 314.852.7274 • For more information please visit: The International Center for Clinical Excellence (ICCE) @ www.centerforclinicalexcellence.com • You may reproduce the handouts, I only ask that you maintain their integrity

  3. Where is Your Head?Recalibrating Our Compasses

  4. Recalibrating Our Compasses • What are the core beliefs or ideas you have about the clients with whom you work (or will work)? • How have you come to believe what you believe and know what you know? What have been the most significant influences on your beliefs? • How have your beliefs and assumptions affected your work with clients? With colleagues? With the community? • Do you believe that change is possible even with the most “difficult” and “challenging” clients? • How do you believe that change occurs? What does change involve? What do you do to promote change? • Would you be in this field if you didn’t believe that the clients with whom you work could change?

  5. HHumanismOOptimismPPossibilitiesEExpectancy “Optimism is the faith that leads to achievement. Nothing can be done without hope or confidence.” - Helen Keller

  6. The Evidence:40 Years of Data

  7. What is Evidence-Based Practice? APA (2006) “The integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” (p. 273) APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285.

  8. Research Resources Key Questions • Whose data is it? • What kind of data is it? • Compared to what?

  9. Three Important Questions • Does psychotherapy work? • How much have our outcomes improved over the past 30 years? • Which models work the best?

  10. The Evidence:Does Psychotherapy Work? • The average treated client is better off than 80% of the untreated sample (NNT)

  11. NNT • NNT = number of patients needed to be treated to attain one additional success versus the alternative

  12. NNT • NNT = number of patients needed to be treated to attain one additional success versus the alternative

  13. The Evidence:Does Psychotherapy Work? • The average treated client is better off than 80% of the untreated sample (NNT) • Therapy is cost-effective and reduces medical expenditures • The average clinician achieves outcomes on par with success rates obtained in randomized clinical trials (RCTs) (with or without co-morbidity)(Minami, et al., 2008) Minami, T., Wampold, B., Serlin, R., Hamilton, E., Brown, G., & Kircher, J. (2008). Benchmarking for psychotherapy efficacy. Journal of Consulting and Clinical Psychology, 75, 232-243.

  14. The Evidence:How Much Have We Improved? • Nearly 10,000 “how to” books have been published on psychotherapy • The number of treatment models has grown to over 400 • Currently there are 145 manualized treatments for 51 of the 397 possible DSM diagnostic grouping • Every approach claims superiority in conceptualization, technique, and outcome • The results?

  15. How Much Have We Improved? • No improvement in outcomes in 30+ years • Dropout rates of 47-50% • Lack of consumer confidence in therapy outcome • Continued emphasis on the medical model, prescriptive treatments, and claims of superiority (relative efficacy) amongst models

  16. The Search for the Best: Claims of Superiority & Relative Efficacy • No differences among treatments intended to be therapeutic (bona fide approaches) including CBT, DBT, IPT, MI, BT, etc., etc…. • Any differences in single studies do not exceed what would be expected by chance and have at most an ES d = .20; NNT = 9 (100% researcher allegiance effects) • What about specific disorders?

  17. Meta- Analyses of Bona Fide Treatments for Specific Disorders • PTSD: All studies published between 1989-2009 • Benish, S., Imel, Z. E., & Wampold, B. E. (2008). The relative efficacy of bona fide psychotherapies of post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review, 28, 746-758. • ALCOHOL ABUSE AND DEPENDENCE: All studies between 1960-2007 • Imel, Z. E., Wampold, B. E., Miller, S. D., & Fleming, R. R. (2008). Distinctions without a difference: Direct comparisons of psychotherapies for alcohol use disorders. Journal of Addictive Behaviors, 22,533-543. • YOUTH DISORDERS-DEPRESSION, ANXIETY, CD, ADHD: All studies between 1980-2006 • Miller, S. D., Wampold, B., & Varhely, K. (2008). Direct comparisons of treatment modalities for youth disorders: A meta-analysis. Psychotherapy Research, 18, 5-14.

  18. The Search for the Best: Dismantling Studies • Specific ingredients are not needed to achieve a good outcome: • Wampold (2001): “Research designs that are able to isolate and establish the relationship between specific ingredients and outcomes…have failed to find a scintilla of evidence that any specific ingredient is necessary for therapeutic change.” (p. 204) • Not convinced? Listen for yourself: http://www.newsavoypartnership.org/2008conference.htm Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Hillsdale, NJ: Lawrence Erlbaum.

  19. Why Haven’t We Improved in Psychotherapy?

  20. Why Haven’t We Improved? Two further questions: • What factors have we held historically as most influential to therapy outcomes? • What accounts for the largest portion of variance between outcomes?

  21. Factors that Contribute Little to Therapy Outcomes • Client factors: diagnosis, gender, and age (<1%) • Therapist factors: age, gender, experience level, professional degree, certification (combined = 0%) • Treatment models (≤1%)

  22. What Accounts for the Largest Portion of Variance Between Outcomes? A Hint….

  23. A Hint: The TDCRP • Treatment of depression – 250; 4 tx cond. – CBT, IPT, IMI, Placebo • CBT vs. IPT • Variance due to tx = 0% • Variance due to therapist = 8% • Actual practice • Type of tx = 0% • Dx, degree, experience = 0% • Medication = 1% • Therapist = 5% • Top ¾ vs. entire population – d = .75 • Antidepressants vs. Placebo • Variance due to tx = 3% • Variance due to prescribing psychiatrist = 9% • Better psychiatrists had better outcomes with placebo than poorer psychiatrists who administered antidepressants

  24. YOU

  25. Therapist Effects: The Upside • 6-9% of the variance in outcome • Second most potent contributor to outcome • 9x > tx effects Wampold, B. E., & Brown, J. (2006). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73(5), 914-923.

  26. How Do You Rate Yourself? • Compared to other mental health professionals within your field (with similar credentials), how would you rate your overall clinical skills and effectiveness in terms of a percentile? Please estimate from 0-100%. For example, 25% = below average; 50% = average; 75% = above average • What percentage (0-100%) of your clients get better (i.e., experience significant symptom reduction/relief) during treatment? What percentage stay the same? What percentage get worse?

  27. How Do We Rate Ourselves? • Researchers surveyed a representative sample of psychologists, psychiatrists, counselors, social workers, and marriage and family therapists from all 50 states: • No differences in how clinicians rated their overall skill level and effectiveness levels between disciplines • On average, clinicians rates themselves at the 80th percentile: • None rated themselves below average • Less than 4% considered themselves average • Only 8% rated themselves lower than the 75th percentile • 25% rated their performance at the 90th percentile or higher compared to their peers Walfish, S., McAllister, B., & Lambert, M. J. (in press). Are all therapists from Lake Wobegon? An investigation of self-assessment bias in health providers.

  28. How Do We Rate Ourselves? (cont.) • With regard to success rates: • The average clinician believed that 80% of their clients improved as a result of being in therapy with them (17% stayed the same; 3% deteriorated) • Nearly a quarter sampled believed that 90% or more improved! • Half reported that none (0%) of their clients deteriorated • The facts? • Effectiveness rates vary tremendously (RCT average RCI = 50%; best therapists = 70%) • Therapists consistently fail to identify deterioration and people at risk for dropping out of services (10 & 47%, respectively) Walfish, S., McAllister, B., & Lambert, M. J. (in press). Are all therapists from Lake Wobegon? An investigation of self-assessment bias in health providers.

  29. How Do We Rate Ourselves? (cont.) • In a study Hannan et al. (2005): • Therapists knew the purpose of the study, were familiar with the outcome measure used, and were informed that the base rate was likely to be 8%; • Therapists accurately predicted deterioration in only 1 out of 550 cases; • In other words, therapists did not identify 39 of the 40 clients who deteriorated • In contrast, the actuarial method correctly identified 36 of the 40 Hannan, C., Lambert, M. J.,Harmon, C., Nielsen, S. L., Smart, D. W., Shimokawa, K., et al. (2005). A lab test and algorithms for identifying clients at risk for treatment failure. Journal of Clinical Psychology: In Session, 61, 155-163.

  30. Therapist Effects:The Downside • Therapists routinely overestimate their effectiveness • Only about 3% of therapists routinely track their outcomes • The effectiveness of the “average” therapist plateaus very early as automaticity sets in Atkins, D. C., & Christensen, A. (2001). Is professional training worth the bother? A review of the impact of psychotherapy training on client outcome. Australian Psychologist, 36, 122-130.

  31. Five Studies Large-Scale RCTs on Outcome Feedback • Harmon, S. C., Lambert, M. J., Smart. D. W., Hawkins, E. J., Nielsen, S. L., Slade, K., et al. (2007). Enhancing outcome for potential treatment failures: Therapist/client feedback and clinical support tools. Psychotherapy Research, 17, 379-392. • Hawkins, E. J., Lambert, M. J., Vermeersch, D. A., Slade, K., & Tuttle, K. (2004). The effects of providing patient progress information to therapists and patients. Psychotherapy Research, 14, 308-327.  • Lambert, M. J., Whipple, J. L., Smart, D. W., Vermeersch, D. A., Nielsen, S. L., & Hawkins, E. J. (2001). The effects of providing therapists with feedback on patient progress during psychotherapy: Are outcomes enhanced? Psychotherapy Research, 11(1), 49–68. • Lambert, M. J., Whipple, J. L., Vermeersch, D. A., Smart, D. W., Hawkins, E. J., Nielsen, S. L., & Goates, M. (2002). Enhancing psychotherapy outcomes via providing feedback on client progress: A replication. Clinical Psychology and Psychotherapy, 9, 91–103. • Whipple, J. L., Lambert, M. J., Vermeersch, D. A., Smart, D. W., Nielsen, S. L., & Hawkins, E. J. (2003). Improving the effects of psychotherapy: The use of early identification of treatment and problem-solving strategies in routine practice. Journal of Counseling Psychology, 50(1), 59–68.

  32. Five Studies Large-Scale RCTs on Outcome Feedback: Findings • All five studies demonstrated significant gains for the feedback groups: • 33% of clients deemed at-risk of negative outcome and in the therapist feedback condition reached reliable improvement versus 22% for TAU • 39% reliable improvement for therapist and client feedback system • 45% reliable improvement: feedback + clinical support tools • Random assignment, no new methods or techniques taught , high % of licensed clinicians who were free to practice as they saw fit Lambert, M. J. (2010). “Yes, it is time for clinicians to routinely monitor treatment outcome. In B. L. Duncan, S. D. Miller., B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed.) (pp. 239-266). Washington, DC: American Psychological Association.

  33. Before You DoAnything Else4 Steps for Improving Clinical Effectiveness

  34. 4 Steps for Improving Clinical Effectiveness • Determine your baseline • Engage in formal, routine, and ongoing feedback • Employ strategies and processes demonstrated to strengthen alliances and improve outcomes • Engage in “deliberate practice”

  35. Step #1Determine Your Baseline

  36. Step #1: Determine Your Baseline • Select an outcome measure that is valid, reliable, and feasible • Examples: OQ-45/LSQ; OQ/Y-OQ 30.2; ORS; SCL-90; Basis 32 (session 1-3 then minimally every third subsequent session) • Can use pencil/paper and or electronic versions • The measure should at minimal elicit the client’s rating of the subject impact of services on majors areas of life (individual, interpersonal, and social role functioning) • Have client complete measure at the beginning of session/meeting

  37. The Outcome Rating Scale (ORS) • A 40 point measure with 4 subscales • Two versions that can be scored: ORS & CORS • Higher score indicate lower levels of distress; lower scores indicate higher levels of distress • Clinical Cutoffs: 25 (> Age 19); 28 (Ages 13-19); 32 (≤ Age 12) • Reliable Change Index (RCI): 5 • Complete at the beginning of session • Takes less than 1 minute to administer • Paper/pencil and electronic scoring systems are available (MyOutcomes; ASIST) • Can plot personal data on Excel spreadsheet • Is free to individual users and available for download at: www.scottdmiller.com

  38. Sample Excel Spreadsheet

  39. Calculating Your Effect Size

  40. Calculating Your Effect Size

  41. Step #2Engage in Formal, Routine, and Ongoing Feedback

  42. Engaging in Feedback • Dose-Response Effect • All major meta-analytic studies indicate the most significant portion of change occurs earlier in treatment (within the first 5 sessions) • The client’s rating of the therapeutic relationship is the most consistent predictor of outcome

  43. APA Task Force:The Importance of Feedback • “The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment to treatment as needed are essential” (p. 280). • “Clinical expertise also entails the monitoring of patient progress (and of changes in the patient’s circumstances—e.g., job loss, major illness) that may suggest the need to adjust treatment (Lambert, Bergin, & Garfield, 2004). If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate.” (p. 276-277) APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285. Lambert, M. J., Bergin, A. E., & Garfield, S. L. (2004). Introduction and overview. In M. J. Lambert (Ed.), Bergin & Garfield’s handbook of psychotherapy & behavior change (5th ed.)(pp. 3-15). New York: Wiley.

  44. What Are We Seeing? “Therapists typically are not cognizant of the trajectory of change of patients seen by therapists in general…that is to say, they have no way of comparing their treatment outcomes with those obtained by other therapists.” (p. 922) Wampold, B. E., & Brown, J. (2006). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73(5), 914-923.

  45. Improving on Your Performance • Excellent performers judge their performance differently • Compare to their personal best • Compare to the performance of others • Compare to known national standard or baseline Ericsson, K. A., Charness, N., Feltovich, P., & Hoffman, R. R. (Eds.) (2006). The Cambridge handbook of expertise and expert performance. New York: Cambridge University Press.

  46. Further Studies onOutcome Feedback • Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 693-704. • Miller, S. D., Duncan, B. L., Sorrell, R., Brown, G. S., & Clark, M. B. (2006). Using formal client feedback to improve retention and outcome: Making ongoing, real-time assessment feasible. Journal of Brief Therapy, 5, 5-22. • Reese, R. J., Norsworthy, L. A., Rowlands, S. J. (2009). Does a continuous feedback model improve therapy outcomes? Psychotherapy, 46(4), 418-431. • Wampold, B., & Brown, J. (2006). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73, 914-923.

  47. Recent Studies on Outcome Feedback: Key Findings • Miller et al. (2006): • 6400+ clients, 75 clinicians • Clients in feedback condition (therapist and client) improved by 65% • Anker, Duncan, & Sparks (2009): • 461 Norwegian couples in marital therapy • Two treatment conditions: (1) routine marital therapy without feedback; (2) routine marital therapy with feedback • Percentage of couples in which both met or exceeded the target or better: • TAU: 17% • Tx with feedback : 51% • Tx with feedback: 50% less separation/divorce at 1-year follow-up

  48. Step #3Employ Strategies and Processes Demonstrated to Strengthen and Alliances and Improve Outcomes

  49. Psychotherapy Common Factors(Meta-Analysis) Effects on Outcomes Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.) (1999). The heart and soul of change: What works in therapy. Washington, D.C.: American Psychological Association. Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94-129). New York: Basic Books. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. New Jersey: Lawrence Erlbaum.

  50. Variance in Psychotherapy Outcomes Client/Extratherapeutic Factors – 87% Treatment Effects – 13% Therapist Effects – 6-9% The Alliance – 5-7% Model/Technique – 1% Factors that account for variance and influence change are not independent entities They are interdependent, fluid, and dynamic

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