Rylie Moore, Ph.D.

PROGRESS MONITORING IN

THERAPY:

Ontario Psychological Associate Association ConferenceNovember 18, 2016

On-going assessment of mental health symptoms and

the therapeutic alliance

PROGRESS MONITORING

• What?

• Why?

• Purpose

• Pantheoretical

• Brief administration time

• Appropriate for use with specific patient population*

• Designed for routine administration

• Comprehensive

• Facilitates assessment and treatment planning

• Sensitive to clinically relevant change

• Information about psychometric properties

PROGRESS MONITORINGImportant considerations

Overington & Ionita, 2012

• Clinicians will benefit from feedback when:

• Clinicians are committed to the goal of improving their

performance

• Clinicians are aware of discrepancies between the goal and

reality

• Feedback source is credible

• Feedback is immediate, frequent, systematic, cognitively

simple, and unambiguous

• Feedback provides concrete suggestions how to improve

PROGRESS MONITORINGContextual Feedback Intervention Theory

Riemer & Bickman, 2004

1. Symptoms

e.g., Depression, anxiety, sleep, substance use, self-harm,

emotional lability, psychosis, trauma, physical symptoms, pain,

etc.

2. Well-being

e.g., subjective well-being emotional distress, motivation,

satisfaction, life enjoyment, etc.

3. Functioning

e.g., work, school, intimate relationships, social, etc.

Assessment: Comprehensive tools

PROGRESS MONITORING

• Behaviour and symptom identification scale-24 (BASIS-

24; Eisen et al., 2004)

• Behavioral Health Measure-20 (BHM-20; Kopta &

Lowry, 2002)

• Clinical Outcomes in Routine Evaluation System-

outcome Management (CORE-OM; Barkham et al.,

1998)

• The Outcomes Questionnaire-45 (OQ-45; Lambert et

al., 1996)

Assessment: Comprehensive tools

See Overington & Ionita, 2012 for a review

PROGRESS MONITORING

• Depression

• BDI-II

• PHQ-9

• HPRSD

• Anxiety

• BAI

• OASIS

• GAD-7

• HADS

• Social Phobia Inventory

• Y-BOCS

• PTSD

• PCL-5

• Wellbeing

• WEMWBS

• Rosenberg SES

• Emotions/Affect

• PANAS

• Everyday Feeling

Questionnaire

Assessment: Specific tools

PROGRESS MONITORING

• Clinician Bias

• Tracking change over time

• Identify when clients are not progressing in

therapy

• Identify what is and is not working

• Change therapy; re-address goals

Benefits of progress monitoring

PROGRESS MONITORING

• Enhance outcomes

• Reactive self-monitoring

• therapist

• client

• PM measures can

• help accelerate client progress (De Jong et al.,

2014)

• shorten length of treatment (Whipple et al., 2003)

• reduce dropout (Whipple et al., 2003)

• reduce no-show rates (Bohanske & Franczak,

2010)

Benefits of progress monitoring

PROGRESS MONITORING

• Reese & Colleagues (2009): Client Feedback vs. TAU

• TAU group: 54% improved (RC); 13% deteriorated

• Feedback group: 80% improved; 4% deteriorated

• Reese & et al. (2009): Therapist Feedback vs TAU

• TAU group: 41% improved; 3% deteriorated

• Feedback group: 67% improved; 4% deteriorated

Research outcomes

PROGRESS MONITORING

• Lambert & Shimokawa (2011): meta-analysis of

not-on-track clients

• the average at-risk client whose therapist

received feedback was better off than

approximately 70% of at-risk clients in the no-

feedback condition

• When CST are used, feedback clients were

better off than 76% of the TAU clients.

Research outcomes

PROGRESS MONITORING

• Lambert et al. 2002: Feedback to therapists

Research outcomes

PROGRESS MONITORING

• Hawkins et al., 2004: Feedback to clients & therapists

• TAU (n = 64): 9% deteriorated, 22% RC, 10% CSC

• Therapist only (n = 70): 3% deteriorated, 30% RC, 10%

CSC

• Therap. & Client (n = 67): 5% deteriorated, 33% RC,

23% CSC

• Treatment non responders generally did not improve

with feedback, except in the therapist/client feedback

condition

Research outcomes

PROGRESS MONITORING

• De Jong et al., 2014: Feedback to clients & therapists

• supported previous findings; largest benefit for

treatment non responders

• Feedback more effective in dual feedback, rather than

to client-only

• Found benefit for short and long-term therapy

• Online format

Research outcomes

PROGRESS MONITORING

PROGRESS MONITORING

• Time efficient; client’s complete questionnaires

between sessions on their own time

• Easy/automatic scoring

• Results available to clinician & client

• Equivalent findings to paper/pencil research

(De Jong et al., 2014; Emmelkamp, 2005)

Benefits of online measurement

Hatfield & Ogles, 2004 p. 487

Practitioners cite, “adds too much paperwork”

and “takes too much times” as primary reason

not to progress monitor

PROGRESS MONITORING

• Consider cognitive limitations (dual diagnosis)

• CST should be validated for repeated

measurement/detecting change

• Be familiar with the relevant test manuals

• Decisions about treatment changes should not be

made solely on the basis of a measure, but should

include clinical judgement

Limitations

THERAPEUTIC ALLIANCE

THERAPEUTIC ALLIANCE

• Freud (1913) initially conceptualized TA as negative transference,

but later considered the possibility of a beneficial attachment

actually developing between therapist and patient (and not as a

projection)

• Zetzel (1956) defines the therapeutic alliance as a non-neurotic

and non-transferential relational component established between

patient and therapist

• Strupp (2001): positive feelings that arise in the patient – feelings

which can lead to the creation of a positive therapeutic climate

from an emotional and interpersonal perspective

What is it?

• Rogers (1951) defines the active components in

the therapeutic relationship as empathy,

congruence, and unconditional positive regard

• Bordin (1979) defines TA as a collaborative

relationship that consists of three essential

elements:

• agreement on goals

• agreement on tasks

• a personal bond made up of positive feelings

THERAPEUTIC ALLIANCEWhat is it?

• Research about common factor associated with

therapy; non-specific factor (Strupp, 2001)

• Corrective emotional experience

• Attachment

• Re-ogranize insecure attachment bonds in

adulthood

• Relational template for future relationships

THERAPEUTIC ALLIANCEWhy is it important?

• Penn Scales (Alexander et al., 1986)

• Vanderbilt Scales (Hartley & Strupp, 1983)

• Toronto Scales (Marziali, 1984)

• Working Alliance Inventory (WAI; Horvath &

Greenberg, 1986, 1989)

• California Scales (Gaston & Marmar, 1994)

• Therapeutic Session Report (Orlinsky & Howard,

1986)

THERAPEUTIC ALLIANCEMeasurement tools

See Ardito & Rabellino, 2011 for a review

• Issues with progress monitoring

• Discussing negative feedback

• Discussing difficult questions

• e.g., I believe my therapist likes me

• e.g., I am confident in my therapist’s ability to

help me

• Differing perspectives between therapist and

client

THERAPEUTIC ALLIANCEMeasurement tools

• What is a rupture?

• Episodes of tension or breakdown in the

collaborative relationship between patient and

therapist (Safran et al., 2011)

• Deteriorations in the relationship between the

client and therapist. (Horvath & Greenberg,

1989).

THERAPEUTIC ALLIANCERepairing Ruptures

• Recognizing when a rupture has occurred

• Markers of client behaviours

• Subtle misunderstandings

• Withdrawal

• Disagreement

• Progress Monitoring

THERAPEUTIC ALLIANCERepairing Ruptures

Horvath & Greenberg (1989)

• How to repair

• Acknowledgement

• Negotiation

• Explore parallel situations

• Consensus

• Develop alternative ways of managing similar

situations

THERAPEUTIC ALLIANCERepairing Ruptures

Horvath & Greenberg (1989)

THERAPEUTIC ALLIANCE

• Fenton et al. (2001) found 6 measures to be strong

predictors of outcomes; none were stronger than

another

• strong alliances predicted positive outcomes

• Safran et al. (1990) concluded that outcomes were more

closely related to successful resolution of ruptures

• Horvath & Symonds (1991) found early ratings of TA

were more predictive of outcomes

Research & benefits of on-going measurement

• Tracey (1989), the more successful the

outcome, the more curvilinear the pattern of

client and therapist session satisfaction

(high–low–high) over the course of

treatment.

• Stiles et al. (2004) found V-shaped alliance

patterns may be correlated with positive

outcomes.

THERAPEUTIC ALLIANCEResearch & benefits of on-going measurement

• Progress monitoring of the TA allows for immediate

feedback about the relationship

• Immediate interventions

• Repair ruptures sooner and more quickly

• Promotes positive framework for feedback in other

relationships

• Enhances self-awareness and assertiveness

THERAPEUTIC ALLIANCEResearch & benefits of on-going measurement

BRINGING IT ALL

TOGETHER• Progress monitoring enhances client outcomes,

especially for client’s who may not be responding to

treatment

• Online progress monitoring is equivalent to

paper/pencil measurement & minimizes perceived

limitations

• TA research demonstrates variable changes to

alliance; progress monitoring allows for feedback

about when to repair ruptures

ENDQuestions?