Supervision For a Change: Four Steps of PCOMS Supervision

httpa://heartandsoulofchange.com 10/14/2014

barrylduncan@comcast.net 1

Barry Duncan, Psy.D. heartandsoulofchange.com561.239.3640 barrylduncan@comcast.net

Supervision for a Change (in both

clients and therapists)

Winter Getaway!Training of Trainers

• Training of Trainers Conference: February 2-6, 2015 (27 CEUs) This intensive training experience gives you all you need to train others and implement PCOMS. And it provides the first step in becoming a PCOMS Certified Trainer.

PCOMS ImplementationGeneral Comments

Change is Hard!Staff need structure and support to make it happen.

Top Ten Reasons Therapists Don’t Want to Do PCOMS

1. The results will be used against me.

2. I already know this information—whether clients are benefiting and I have a good alliance.

3. It will Interfere with the relationship—just more paperwork.

4. It’s naïve to think that we can always follow client direction or privilege the client’s view.

5. This won’t work with my client population.

6. A 4-item measure is too simple to be valid.

7. People will lie on these measures or try to please

8. You can’t reduce people to a number.

9. Clients won’t do it; insensitive when they are in crisis.

10. This doesn’t fit my therapy model; it’s for brief therapy only.

Top Ten Therapist Motivations for PCOMS

1. I want to improve my effectiveness.

2. I like how client feedback can help me expand my skills.

3. I like the idea of consumer participation.

4. I like the structure and focus it provides.

5. I want to do evidence based practices.

6. I like this evidence based approach better than specific treatments for specific diagnoses or learning more models.

7. I like the research support (the 4 RCTs) for PCOMS & the importance of the client & the alliance to outcome.

8. I want to develop as a therapist & this helps me know if I am.

9. I want to be accountable for my services.

10. I like the idea of client privilege/empowerment/social justice.

Openly Address Concerns Build Trust: Transparency Rules

•Required, but will not be used in any punitive way

•The purpose is to partner with consumers to raise the quality of services, and to prove the value of our services in a way that makes clinical sense

What’s Up3 of the 4 Secrets

1) In It for the Long Haul—organizational commitment at all levels; “We Want to Implement”

2) Love Your Data—collection and use of data right out of the gate; Nothing Organic!

3) Inspire the Front-Line Clinician—connecting PCOMS to therapist’s desire to do good work & improve over their careers… research on 11K therapists

1) In It for the Long Haul—organizational commitment at all levels; “We Want to Implement”

2) Love Your Data—collection and use of data right out of the gate; Nothing Organic!

3) Inspire the Front-Line Clinician—connecting PCOMS to therapist’s desire to do good work & improve over their careers… research on 11K therapists

HSCP Readiness ChecklistIn It for the Long Haul

1. Board of Directors approval of & support for PCOMS.

2. Consensus among senior managers that consumer partnership, accountability, & PCOMS are central features of service delivery.

3. A business/financial plan that incorporates PCOMS.

1. Board of Directors approval of & support for PCOMS.

2. Consensus among senior managers that consumer partnership, accountability, & PCOMS are central features of service delivery.

3. A business/financial plan that incorporates PCOMS.

4. Regular communication w/funders about PCOMS data

5. A HR training & dev. plan that supports ongoing PCOMS ed., including a core group of internal PCOMS trainers, & seeks to integrate PCOMS into therapist dev. plans, performance appraisals, & hiring practices.

6. Infrastructure (support staff, IT, hardware, etc) to support the collection & analysis of PCOMS data at consumer to agency levels.

4. Regular communication w/funders about PCOMS data

5. A HR training & dev. plan that supports ongoing PCOMS ed., including a core group of internal PCOMS trainers, & seeks to integrate PCOMS into therapist dev. plans, performance appraisals, & hiring practices.

6. Infrastructure (support staff, IT, hardware, etc) to support the collection & analysis of PCOMS data at consumer to agency levels.

7. Supervisory infrastructure that uses data to identify at risk clients, proactively address needs, & improve therapist performance.

8. A structure & policy for addressing clients who are not progressing that ensures rapid transfer and continuity of care.

9. Incorporates consumer partnership, accountability, & PCOMS as central features in both “Mission Statement” and “Client Rights documents.”

7. Supervisory infrastructure that uses data to identify at risk clients, proactively address needs, & improve therapist performance.

8. A structure & policy for addressing clients who are not progressing that ensures rapid transfer and continuity of care.

9. Incorporates consumer partnership, accountability, & PCOMS as central features in both “Mission Statement” and “Client Rights documents.”

Data Is More than Just a Friend…

PCOMS Implementation: 4 Secrets2. Love Your Data

Love Your DataCollect Data from the Beginning

Used to think it could happen organically

What was I thinking! Collecting data allows:

knowing who is and whoisn’t doing it; who is and isn’t doing it correctly; data integrity (more on this later); real agency benefit

Used to think it could happen organically

What was I thinking! Collecting data allows:

knowing who is and whoisn’t doing it; who is and isn’t doing it correctly; data integrity (more on this later); real agency benefit

Therapists Do the Work Because They Want to Make a Difference

Therapists Want to Improveover Their Careers

Therapists Need to Growto Avoid Burnout

PCOMS Implementation: 4 Secrets3. Inspire the Front Line ClinicianPCOMS Implementation: 4 Secrets

3. Inspire the Front Line Clinician

Question #1:

Finding the right approach or selecting evidence based treatments will improve outcomes

FalseStudy after study, and studies of studies show that all treatments are the right treatment—for some clients.

How Do We Get BetterPop Quiz

Question #2:

Personal therapy and increasing our self awareness makes us a better person and improves our outcomes

FalseWhile helpers find personal therapy invaluable, it neither helps nor hinders outcomes.

Geller, J., Norcorss, J.,& Orlinksky D. (2005). The psychotherapist’s Own Psychotherapy. New York: Oxford Univ. Press.

How Do We Get BetterPop Quiz

Question #3:

Professional Training and Continuing Education have a direct impact on outcomes.

FALSENo difference in outcomes between disciplines, training models, and not one study supports CE as helping outcomes

How Do We Get Better?Pop Quiz

Question #4:

The accrued wisdom of clinical experience, years of seasoning, improves outcomes

FALSEThe cold hard reality is that experience seems to make little difference.

Meta-analysis by Lambert & Shimokawa (2011)of PCOMS (the ORS and SRS)

Those in feedback group had 3.5 higher odds of experiencing reliable change

Those in feedback group had less than half the odds of experiencing deterioration

Feedback attained .48 ES

Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72-79.

Inspire the Front Line ClinicianMonitor & Quicken Your Development

Feedback tailors services based on response, provides an early warning system to prevent negative outcomes, & solves helper variability—feedback improves performance andit both monitors and quickens development

But How Do You Get Them To See the Benefits?

The evidence? Maybe…Management dictates?

Maybe…Devotion to consumer

privilege? Maybe…Openness to new ideas?

Maybe…(older less so) But not likely!

The evidence? Maybe…Management dictates?

Maybe…Devotion to consumer

privilege? Maybe…Openness to new ideas?

Maybe…(older less so) But not likely!

TherapistsReaction to PCOMS

The Fact: Only 25-33% Implement on Their Own

The Rest Have to Be Dragged Kicking and Screaming—not really but It Takes Ongoing Support/Motivation/Inspiration via Supervision

But Most Therapists Won’t Do It Despite the Evidence

PCOMS Implementation4 Secrets

1) In It for the Long Haul—organizational commitment at all levels;

2) Love Your Data—collection and use of data right out of the gate;

3) Inspire the Front-Line Clinician—connecting PCOMS to therapist’s desire to do good work & improve over their careers;

4) Supervision for a Change--in both clients and therapists

1) In It for the Long Haul—organizational commitment at all levels;

2) Love Your Data—collection and use of data right out of the gate;

3) Inspire the Front-Line Clinician—connecting PCOMS to therapist’s desire to do good work & improve over their careers;

4) Supervision for a Change--in both clients and therapists

Isomorphic Supervision Just the Facts Ma’am

The nuts & bolts of isomorphic, PCOMS supervision.

PCOMS Supervision: Key toClient Benefit & Helper Growth

Based on outcome data not theory or pontification.

Aimed at early identification of clients at risk so services can be modified.

Offers feedback, support, training for those who aspire to become better

Based on outcome data not theory or pontification.

Aimed at early identification of clients at risk so services can be modified.

Offers feedback, support, training for those who aspire to become better

Reviewing GraphsFirst Things FirstReviewing GraphsFirst Things First

Squeamishness Trajectories

(ETR) Clinical Cut Off Percent of

Change Target—Basis for Feedback Messages

Squeamishness Trajectories

(ETR) Clinical Cut Off Percent of

Change Target—Basis for Feedback Messages

This means that clients who report little or no progress early on will likely show no improvement over the entire course of therapy, or will end up on the drop-out list—early change predicts engagement in therapy and a good outcome at termination. Provides a tangible way for us to identify folks who are not responding so that we can chart a new course.

The Research about Early Change Is a Gift

Early Change Doesn’t Fit My Clients!Some Clients Take Longer

It is true that some clients take longer than others, but importantly not for change to start, but rather for change to plateau

Baldwin, S., Berkeljon, A., Atkins, D., Olsen, J., & Nielsen, S. (2009). Rates of change in naturalistic psychotherapy: Contrasting dose-effect and good-enough level models of change. Journal of Consulting and Clinical Psychology, 77(2), 203-211.

Some clients do take longer, but the mythology never dies

N=4676; 77% attended 8 or less, and 91% 12 or less

Note that even for the clients who take longer (last curve bottom right), change starts early…just is flatter

Sudden Epiphany? NOTSudden Epiphany? NOT

Myth: Clients flat-line & then spike. Some clients do take longer but change starts right away. So the question remains: When do you start getting worried when clients are not responding? I vote for sooner rather than later.

What People ForgetWhat People Forget

Not Just Flicking a Form… 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 Sincerely, Make It Their Own

Worthless Unless Data Are Used to Identify at Risk Clients…and then Do Something about Them.

Not Just Flicking a Form… 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 Sincerely, Make It Their Own

Worthless Unless Data Are Used to Identify at Risk Clients…and then Do Something about Them.

Fidelity Monitoring ToolFidelity Monitoring Tool

1. Administer and score the Outcome Rating Scale (ORS) each visit or “unit of service.”

2. Ensure that the client understands that the ORS is intended to bring his or her voice into the decision-making process and will be collaboratively used to monitor progress.

3. Ensure that client gives a good rating; i.e., a rating that matches the client’s description.

4. Ensure that the client’s marks on the ORS are connected to the reasons for service.

1. Administer and score the Outcome Rating Scale (ORS) each visit or “unit of service.”

2. Ensure that the client understands that the ORS is intended to bring his or her voice into the decision-making process and will be collaboratively used to monitor progress.

3. Ensure that client gives a good rating; i.e., a rating that matches the client’s description.

4. Ensure that the client’s marks on the ORS are connected to the reasons for service.

5. Use outcome (ORS) data to develop and graph individualized trajectories of change. 6. Plot client progress (ORS scores) on individualized trajectories from session to session to determine which clients are making progress and which are at risk for a negative or null outcome7. Use ORS scores to engage clients in a discussion in every session about how to continue to empower change if it is happening and change, augment, or end tx if it is not.8. Administer and score the Session Rating Scale (SRS) each visit or “unit of service.”

9. Ensure that the client understands that the SRS is intended to create a dialogue between therapist and client that more tailors the service to the client--and that there is no bad news on the measure.10. Use the SRS to discuss whether: the client feels heard, understood, and respected; the service is addressing the client’s goals for treatment; the service approach matches the client’s culture or worldview, or theory of change.

Fidelity Monitoring ToolFidelity Monitoring Tool

PCOMS Therapist Adherence ScalePCOMS Therapist Adherence Scale

Never Sometimes Often Regularly Always 1 2 3 4 5

Out of a total possible 50 points, adherence is considered acceptable at 40 or above at the 6 month mark and 45 or above at the one year after implementation. High adherence is ensured by the PCOMS supervisory process.

Never Sometimes Often Regularly Always 1 2 3 4 5

Out of a total possible 50 points, adherence is considered acceptable at 40 or above at the 6 month mark and 45 or above at the one year after implementation. High adherence is ensured by the PCOMS supervisory process.

Supervision: Four StepsSupervision: Four Steps

2. Look for over-utilization; Spend most time on at risk clients: shape discussion and brainstorms options 3. Review stats & discuss ways to improve; Encourage action4. Mentor via skill building, client teachings, & ongoing reflection

1. Start with graphs of all clients not reflecting benefit; Alsoinclude scores in general. Ensureuse of measures & data integrity.

PCOMS SupervisionData Integrity: What to Look For

• 30% of Intakes over the Cutoff:• Client or therapist does not understand

ORS –Role play introducing the ORS• ORS Scores between 35-40:• Client or therapist does not understand

the measures; Rarely a good score; even mandated clients don’t score this high. Role play introducing the ORS, discussing score when it doesn’t match client description of experience

• ORS Scores Look Like a Saw• An emotional thermometer: Client or

Therapist does not understand ORS—Role play connecting the client’s reason for service to the marks on the ORS.

30% of Intakes over the Cutoff

Intake ORS Scores 1.28.72.17.53.31.74.18.95.12.46.29.67.33.68.7.69.13.710.30.6

• Client or therapist likely does not understand ORS –Role play introducing the ORS

The First MeetingIntroducing the ORS

Introduce the ORS using your own words—convey the notion of monitoring outcome and ensuring client voice is heard

Measure the marks and add the scores

Introduce the ORS using your own words—convey the notion of monitoring outcome and ensuring client voice is heard

Measure the marks and add the scores

ORS Scores between 35-40Intake ORS Scores1.28.72.17.53.36.74.18.95.12.46.29.67.38.68.7.69.13.710.38.6

• Client or therapist does not understand the measures; Rarely a good score; even mandated clients don’t score this high. Role play introducing the ORS, discussing score when it doesn’t match client description of life

The First MeetingGetting A Good Rating

1. Score ORS & give feedback re score & cutoff; 2. Client describes situation inconsistent w/score; 3. Practice checking it out with the client

ORS Scores1.28.7, 17.1, 26.4, 12.7, 29.92.17.5, 19.6, 22.43.31.7, 12.2, 28.4, 6.7,4.18.9, 19.2, 19.75.12.4, 18.3, 9.9, 21.1, 11.86.29.6, 31.37.33,6, 9.3, 8.6, 34.9, 31.6, 3.48.7.6, 8.5, 9.59.13.7, 14.5, 17.5, 20.810.30.6

ORS Scores Look Like a SawThe Emotional Thermometer

Client or Therapist does not understand ORS—Role play connecting the client’s reason for service to the marks on the ORS

See SawSee Saw

Has to be Relevant to the Work

Or Becomes an Emotional Thermometer of Day to Day Life

Has to be Relevant to the Work

Or Becomes an Emotional Thermometer of Day to Day Life

Integrating the MeasuresProblems and Challenges?

The First MeetingIntegrating the Measures

1. Score ORS & give feedback re score & cutoff; 2. Connect marks to client description & reason for service; 3.Use examples from work & report

Reviewing GraphsOver Utilization

Creates wait lists, iatrogenic effects. First way is when the client continues in service in the absence of benefit.

Reviewing GraphsOver Utilization

When max benefit reached, talk about stepping down; not discharge, but planning for continued recovery out of tx.

If not stepped down, graphs look like a saw, rising and falling with everyday life; clients are disempowered

ORS represents life in general instead of client's perceptions connected to the purpose of the service.

When max benefit reached, talk about stepping down; not discharge, but planning for continued recovery out of tx.

If not stepped down, graphs look like a saw, rising and falling with everyday life; clients are disempowered

ORS represents life in general instead of client's perceptions connected to the purpose of the service.

First order of business:What does the client say about this?

SupervisionGeneral Considerations

What does the client want?

What are the client’s ideas about change

What are the client’s expectations about our role?

What are the client’s strengths?

What does the client want?

What are the client’s ideas about change

What are the client’s expectations about our role?

What are the client’s strengths?

1.What does the client say?2.Is the client engaged? SRS?3.What has the helper done differently?4.What can be done differently now?5.What other resources can be rallied?6.Is it time to fail successfully?

Supervisory ConversationThe Longer w/o Change, the Quicker to #6

Brainstorming: From Thinking About Doing Something Different to Doing ItBrainstorming: From Thinking About

Doing Something Different to Doing It

What else can be done!?

People, places, things: Colleague or sup. consult; someone else from client support network; community support; faith based; peer recovery; or different provider…

What else can be done!?

People, places, things: Colleague or sup. consult; someone else from client support network; community support; faith based; peer recovery; or different provider…

1.What does the client say?2.Is the client engaged? SRS?3.What has the helper done differently?4.What can be done differently now?5.What other resources can be rallied?6.Is it time to fail successfully?

Supervisory ConversationThe Longer w/o Change, the Quicker to #6

Infrastructure for Non-Blaming Transfer

Not dumping clients Says nothing about

competence of therapist Says nothing about

client’s ability to change Says everything about

doing something positive and proactive about clients who are not benefiting

Not dumping clients Says nothing about

competence of therapist Says nothing about

client’s ability to change Says everything about

doing something positive and proactive about clients who are not benefiting

Therapists Learn to Be Helpful byMoving Clients to Greener PasturesTherapists Learn to Be Helpful by

Moving Clients to Greener Pastures

Learn that all of us have clients who don’t benefit

If supervision re-visits these clients, therapists will see the transferred clients benefitting

Therapists have new way to help and feel good about the work

Learn that all of us have clients who don’t benefit

If supervision re-visits these clients, therapists will see the transferred clients benefitting

Therapists have new way to help and feel good about the work

Love Your DataKey Performance Indicators

1. Average Change: Is it above 6?

2. % reaching reliable and significant change

3. Effect Size

1. Average Change: Is it above 6?

2. % reaching reliable and significant change

3. Effect Size

Love Your DataMyOutcomes.comLove Your Data

MyOutcomes.com

The single bit of info that tells you the most is the % who reach target—the mean trajectory for clients entering services with the same intake score.

Collaboratively Form a Plan Improve/Foster DevelopmentCollaboratively Form a Plan

Improve/Foster DevelopmentDiscuss stats openly and

ask for supervisee’s ideas Co-develop a plan and

implement; evaluate quarter by quarter; modify if outcomes not improving

Foster continued professional reflection

Discuss stats openly and ask for supervisee’s ideas

Co-develop a plan and implement; evaluate quarter by quarter; modify if outcomes not improving

Foster continued professional reflection

Becoming BetterConsider Benefits of Tracking Outcome

Allows a systematic trial and error application of new learning as well as the refinement of the tried and true mechanisms that we know enhance outcomes.

Tracking cumulative career development enables reflection and action about effectiveness.

Allows a systematic trial and error application of new learning as well as the refinement of the tried and true mechanisms that we know enhance outcomes.

Tracking cumulative career development enables reflection and action about effectiveness.

Becoming BetterTake Charge

Track effectiveness by active/inactive differences; 30 client block a good est.

Keep dev. front & center; implement ideas, practices, & models, as well as building skills.

Will readily see whether efforts are paying off, if chosen methods of increasing effectiveness need to be tweaked or changed outright.

Track effectiveness by active/inactive differences; 30 client block a good est.

Keep dev. front & center; implement ideas, practices, & models, as well as building skills.

Will readily see whether efforts are paying off, if chosen methods of increasing effectiveness need to be tweaked or changed outright.

Cumulative Career DevelopmentStart with the Common FactorsCumulative Career DevelopmentStart with the Common Factors

Models/techniques, but… Focus on the common

factors. Practice well the skills of

the craft—the alliance. At some point, craft becomes art. Relational repertoire likely parallels your development

Models/techniques, but… Focus on the common

factors. Practice well the skills of

the craft—the alliance. At some point, craft becomes art. Relational repertoire likely parallels your development

Leave Time in Each MeetingContinual Professional Reflection

Skill Building, Role-plays: Practice the skills of the craft; learn new techniques

Learn from Clients: Tease out what is working and what is not using client outcome as a guide.

Talk about therapist identity and encourage an evolving description of the work

Skill Building, Role-plays: Practice the skills of the craft; learn new techniques

Learn from Clients: Tease out what is working and what is not using client outcome as a guide.

Talk about therapist identity and encourage an evolving description of the work

Helping Supervisees Learn from Clients

Provider experiences of their current development are influenced mainly by the quality of their clinical experiences w/clients.

Supervision can help helpers make the best of it.

Provider experiences of their current development are influenced mainly by the quality of their clinical experiences w/clients.

Supervision can help helpers make the best of it.

Currently Experienced GrowthClients Are the Best TeachersCurrently Experienced GrowthClients Are the Best Teachers

Impossible to sit w/people& witness journey to a better place & not be changed.

Teach us about the human condition & ways people transcend adversity & cope w/the unthinkable.

Tracking outcomes takes this notion to a different & more immediately practical level.

Impossible to sit w/people& witness journey to a better place & not be changed.

Teach us about the human condition & ways people transcend adversity & cope w/the unthinkable.

Tracking outcomes takes this notion to a different & more immediately practical level.

Tracking Outcomes: Keeps Our Utmost Attention on the Here and Now

Clients teach us with their responses about the benefit & fit of service—as well as their reflections about the next step. Those clients not responding to our therapeutic business as usual help us step outside of our comfort zones.

• Review current clients, consider lessons. Did you experience anything different? Did you do something you have never done when clients were changing, when they weren’t? Has this changed your work? What does this mean in terms of how you think about your work and your identity as a therapist?

Reviewing Your Currently Experienced Growth

Learning from ClientsOur Norwegian Colleague

I became more transparent, more courageous. I felt more secure and conveyed it.

Clients and I got more concrete about change, how it started, and what else would be helpful.

Feedback sharpened my focus—pinpointed that we have a common purpose.

I became more transparent, more courageous. I felt more secure and conveyed it.

Clients and I got more concrete about change, how it started, and what else would be helpful.

Feedback sharpened my focus—pinpointed that we have a common purpose.

Our Norwegian Colleague (cont)Be Proactive

Feedback helped me take risks and invite negative comments.

Made me more secure, I am far more daring. I am now more collaborative and allow things to emerge rather than following a set way to work.

Feedback helped me take risks and invite negative comments.

Made me more secure, I am far more daring. I am now more collaborative and allow things to emerge rather than following a set way to work.

Reflect about your identity & construct a story of your work that captures what you do.

Edit and refine your identity & accounts—evolve a description that you can have allegiance to but that doesn’t lead to dead ends.

Reflect about your identity & construct a story of your work that captures what you do.

Edit and refine your identity & accounts—evolve a description that you can have allegiance to but that doesn’t lead to dead ends.

You Do What?Identities and Descriptions

You Do What?What is Your Identity?

How do you describe what you do? At your very best, what role do you play with your clients? What recent client represents the essence of your identity, illustrating what you embrace most about your work?

You Do WhatLabor or ArtYou Do WhatLabor or Art

What we do is a measure of who we are. If we imagine our work as labor, we become laborers. If we imagine our work as art, we become artists.

Jeffrey Patnaude

What we do is a measure of who we are. If we imagine our work as labor, we become laborers. If we imagine our work as art, we become artists.

Jeffrey Patnaude

You’ll Have Them When…CEG Kicks In

You’ll Have Them When…CEG Kicks In They have conversations with

clients in ways not seemed possible before

They experience that first client who benefits

They recapture success with clients who would have ended negatively

They learn from clients and experience their current growth…they learn from you

They have conversations withclients in ways not seemed possible before

They experience that first client who benefits

They recapture success with clients who would have ended negatively

They learn from clients and experience their current growth…they learn from you

Supervision For a Change: Four Steps of PCOMS Supervision

Education

Transcript of Supervision For a Change: Four Steps of PCOMS Supervision

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