SCORE PROJECT

Researching therapy through its effects on the everyday lives and relationships of clients.

Peter Stratton and Judith LaskUKCP Research Conference July 2015What is particular about Systemic Therapy?What are the research challenges ?

A broad range of approaches and methodsFamily Therapy, Couple Therapy, individual Systemic Therapy, Narrative therapy, Brief Solution Focused Therapy, Structural Therapy, Strategic Therapy, Dialogic Therapy, Post Milan Therapy, Milan Therapy, Social Constructionist Therapy, Attachment/Narrative Therapy, Contextual Therapy and so onRaises issues about the nature of change that is sought by therapist What is useful to measure? PassionTherapists can be very passionate about their approachfall in love with their particular brand of therapy make assumptions about efficacy that they do not want to open to scrutiny Assume the complexity of what they do could never be measuredWorry that the process of measurement can be a straightjacket on the therapy.

Collaborative ApproachWe are interested in clients viewsWe know professionals may measure change in a different way from families and family members may have differing views about what they want to change and different experiences of the change processSometimes the problem may not change but relationships to the problem may change.

Challenges to the Systemic Researcher What do you measure?What family processes are associated with positive change ( whatever that might be). Are changes in family processes necessary or relevant?What kind of measure can appeal to researchers and clinicians so it will be used?How can family members be fully participant in the process of understanding what happens in therapy and what is useful change?Political ContextEmphasis on evidence based practiceMost Systemic Psychotherapists employed in services which rely on government funding.Increased emphasis on individualised diagnostic categoriesNarrowing of range of psychological therapies available outside private sector.Some polarisation of the art and science of therapy.How can we find out what we need to know in order to be more effective ?An important gap was the lack of an easy to administer self report measure that makes sense for systemic work and can be used clinically as well as for research.We reviewed existing measures and found that none really did this jobWe were familiar with CORE and appreciated what it was trying to do and decided to create a measure which honored CORE but with a focus on family function.

9So how about a systemic version of CORE?

So how about a systemic version of CORE?SCORE Peter Stratton N'hampton CAMHS June 2014 9Why Family Processes?Some systemic therapists are interested in how symptoms develop in an attempt to cope with the way the family has operated its relationships.Others are more focused on building the underused capabilities of patients and their families.All believe that healthy family processes will help a designated patient to overcome their difficulties and maintain therapeutic change.So the ways the family members describe their life at home should be a crucial indicator of the resources the patients have .1010Some crucial Areas of Interest backed up by research1. communication2. management of emotions in families/ expression and containment3. attachment/ safety, intimacy, love,care4. Family and individual beliefs and narratives5. Patterns of Behaviour/ 6. interaction with outside world7. Validation8.Individual and family life cycle. Needs and transitions9 Family strengths and resilience.10 Problem solving capacity.

First Steps along the wayReviewed current measures and measures used in FT researchConvened an expert reference group of Systemic Psychotherapists and trainers to develop a 45 item measure and develop the structure of the questionnaire. This was with the aim of trialing the longer measure and eventually developing a 15 item measureSome UnderpinningsThe measure would focus on family strengths and resilience as well as potential problem areas.It would respect differences within families ( that is each family member would have a voice to express their experience)It would respect different family forms and cultural contexts. We asked families to define themselves.It would respect that families are experts on themselves and be self report

Some UnderpinningsIt would draw from clinical and research knowledge about families as well as well developed theory.It would be qualitative but also contain space for quantitative data.Although it is developed for work with families changes in family function are pertinent to many psychological interventions.It would be relevant across a range of families at different life cycle stages and with different presentations

29 therapists using SCORE in a research network40% had not used any outcome measure before using SCORE. There was some concern about the effect using SCORE might have on the therapy; generally it took about 4 times using it before it became an unproblematic routine but for some it never did. Effect on the therapy ranged from neutral to very positive. 82% were sure they would continue to use it; only one definitely would not. Peter Stratton N'hampton CAMHS June 2014 15Some Clinical uses of SCOREPre-treatment information and screeningDiscussing the items that are significant for clientsIndicating major areas of change, and of no change, between sessionsA context for discussions of usefulnessUsing the items to alert family members to disregarded aspectsChecking for difference between therapist and client perceptionsDiscussing differences between perceptions od different family members16 Peter Stratton N'hampton CAMHS June 2014 DevelopmentsWe realised the need for translations of the measure for both language and cultural reasons and we have organised a programme of translations into a range of languages across Europe and beyond.We wanted these to be meaningful to local populations but stay close to the standard 15 item measure to make cross cultural research and comparisons possible/Peter has worked hard with EFTA in Europe and the translations have by and large been done with a standard protocol.Translation Commission 5 translations from the English version by fluent English speakers who have the target language as their first language ( or one of their first languages). These 5 should include: at least one mental health professional with systemic training, at least two lay persons differing in age, ( over 12) gender or social class and someone who has significant experience of translation.

1818Test in clinical contextTranslate according to protocolEstablish ethics and gain family consentAdminister at 1st, 4th and final sessionHave therapist rate change at 4th and last sessionRecord all consecutive families Send data anonymouslyKeep a copy for own use.1919Increasing the Use of the measureIt is difficult to encourage people who are not used to it to use measure lots of anxieties about effect on familiesThe CYP IAPT developments have led many people previously resistant to value ROMS and the Systemic Family Practice students and practitioners use Score.This increased use throws up different issues and concernsRecent developmentsTom Jewell has developed a version for 8-12 year olds

Yang Yang The trialed it with a group from the LGBT community and professionals working with them and made some suggestions for alteration of wording to increase acceptability. We are working on a version specifically for couples.So what does SCORE look like?And why?And how?

clients rating concrete aspects of their lives that are relevant to what will be needed for the therapy to be effective.

2223For each line, would you say this describes our family: 1. Describes us: Very well2. Describes us: Well3. Describes us: Partly4. Describes us: Not well5. Describes us: Not at allIn my family we talk to each other about things which matter to us People often dont tell each other the truth in my familyEach of us gets listened to in our familyIt feels risky to disagree in our familyWe find it hard to deal with everyday problemsWe trust each other24

Consultation stageA 16 item Likert scale createdFormal and informal expert consultationService user consultationLay consultation, including deliberate sampling of people from diverse ethnic backgrounds2525Qualitative PRNPiloting an early versionThree therapists each interviewed three experienced therapists about SCOREThematic analysis of therapeutic judgements.Pooling of analysesTape recording responses to individual itemsSee what we found in the Australian & New Zealand Journal of Family Therapy 2006.Responses of 33 FT trainees simulating family members. Clear difference between functional and not.Etc etc.2626

27ingredients making some more systemic than othersEthical ApprovalNRES Ethical approval was granted in January 2006 for multi-site piloting of SCORE.Each pilot site needs to register with COREC to initiate application. Close attention to confidentiality, patient information, informed consent, data storage & custodianship.2828Expand and contract and testQual and quant data used to generate items, reduced to 55.Piloted on therapists and non-clinical samplesReduced to 40 items. Advice that the development should be in the context of how we plan for it to be used. So applied to families as they come for systemic therapy.Recruited clinics throughout the UK.

2929The families-in-therapy projectSCORE 40 given to individual family members at start of first session.228 families, 510 SCORE 40s. Cronbach Alpha, is .934, and Split-half reliability is a correlation of .833. It is coherent. Every item correlates with the corrected average.High levels of acceptability of all itemsThe SCORE 40 worksNow we really got going.

3030Now we make it more practicableCan we do with far fewer items?Yes we canItems were checked for how well they correlated with the total SCORE; whether they distinguished clinical and non-clinical, how they worked in MR and FA.The weaker items were examined for clinical significance.We ended up with 15 items that factor into 3 clear dimensions3131Characteristics of the SCORE 15Factor 1. Strengths and adaptabilityFactor2. Overwhelmed by difficultiesFactor 3. Disrupted communicationIn the full sample of 608 cases SCORE 15 explained 95% of the variance in the means of the full SCORE 40.

Alan Carr and his researchers in Dublin conducted a similar process with >700 mostly non-therapy individuals and has created a 28 item version that correlates highly with several family measures, especially the Family Assessment Device. It has the same factor structure.

3232Factor 1. Strengths and adaptabilityIn my family we talk to each other about things that matter to us We are good at finding new ways to deal with things that are difficult

3333Factor2. Overwhelmed by difficultiesWe seem to go from one crisis to another in my family Things always seem to go wrong for my family It feels miserable in our family3434Factor 3. Disrupted communicationPeople often dont tell each other the truth in my family It feels risky to disagree in our family People in the family are nasty to each other 3535Rating helpfulness of FT session 1&436

Peter Stratton N'hampton CAMHS June 2014 55Family descriptions of those with highest scoresbroken down, lonely, unsupportive, lacks trust and regard, a war zone hurt, bitter, cruel, painful, distrusting, crushed disjointed, undisciplined, nasty at timesunhappy, unable to communicate and find a compromise miserable,bad environment,stressful, upsetting,overprotective, acrimonious, disharmonious, distrustfulegg shells nightmare, bullying and controlin crisis, son's violenceintensity of love & despair, logic seen as right, feelings wrong

3737Hoped for changedaughter's behaviour family life work/life: my husband getting his interest back blame & competition over our son understanding each other dependence would like to be independence f part's health daughter's ill health tolerance of each other's different opinions the way we deal with our problems

3838

A simple question: can you tell us how you felt about filling in this questionnaireOk, fine etc horrible, vulnerable, frightening. selfharm v hitting very sad, upset ok, hopefully helpful answers should be on scale of 1- 10 thoughtful my back hurts so I was irritable anxious & tearful useful to assess family life, helpful to confirm in writing very helpful to analyse our family dynamics

3939Some issues we need to think aboutevaluating outcome. Through real life aspects that the theory of therapy indicates. Status of family member reports of life at home. Issue of the therapy choosing what its objectives are and then measuring them. Therefore needs validation outside of judgements made by the faithful.Are we repeating the old pattern e.g. with Beck constructing a measure of the kinds of cognitive changes that his form of therapy tried to achieve. 4040Suggestions of research uses of SCOREGenerating an evidence base appropriate to relational therapiesExamining effects of therapy with:Different lengthsDifferent client groupsDifferent approachesCollaboration across countries. Multi-country collaboration through the European Family Therapy AssociationA national data-basePractitioner Networks of researchersExploring cultural differences between families.41A wellbeing measureOverall, how satisfied are you with your life nowadays?not at all completely0 -----------------------------------------------------------------10Overall, to what extent do you feel the things you do in your life are worthwhile?0 -----------------------------------------------------------------10Overall, how happy did you feel yesterday?0 -----------------------------------------------------------------10Overall, how anxious did you feel yesterday?0 -----------------------------------------------------------------10

Peter Stratton N'hampton CAMHS June 2014 42Best Available Research

Patient Characteristics,Culture, & Prefs

Clinical ExpertiseEBP DecisionsJohn Norcross, UKCP 2011 Peter Stratton N'hampton CAMHS June 2014 4343Research is not about digging for nuggets of truthIt is about creating new meanings (Silverman)

GOD Peter Stratton Birmingham April 20144445We need:Psychological health systems that recognise that there is an enormous amount still to learn about psychotherapy and about fostering better relationships. This means supporting research that will release the benefit of what has been learned in the full range of relevant therapeutic practice, and service provision that maintains the variety of promising therapies which are researched every whichway.45