Abandoning a Traditional Intake System: A Leap of Data-Informed Faith

1. Abandoning a Traditional Intake System:A Leap of Data-Informed Faith Kara Cattani, Ph.D.

2. Previous Findings With a Traditional Intake System Our clients sometimes complained about telling their problems first to an intake therapist, then again to the therapist by whom they are to be treated, a pattern we called intake therapist discontinuity (ITD) Two previous studies had examined premature termination and intake therapist discontinuity; neither examined treatment cost or outcome Wise & Rinn (1983) found that ITD clients at an Alabama community mental health center were more likely to terminate prematurely (before session 4) Gottheil, Sterling, Weinstein & Kurtz (1994) found that ITD clients at a Philadelphia cocaine treatment facility were no more likely to termination prematurely (before session 3) We studied outcome and session costs associated with intake therapist discontinuity over an 11 year period at the BYU Counseling and Career Center

3. Previous Intake Therapist Discontinuity Patterns at BYU Psychotherapy database 1996 - 2010 Appointments (intake, individual therapy, group, biofeedback, etc.) and results (kept as sessions, missed as no shows cancelled, rescheduled) Therapist IDs Session-by-session OQ-45s 1996 to 2006, 15,137 (84.8%) of 17,854 clients attended intake sessions and scheduled 1 or more subsequent appointments Intake therapist discontinuity: 8,423 clients (55.6%) assigned to 2nd appointments with therapists different from their intake therapists Intake therapist continuity: 6,714 (44.4%) scheduled with their intake therapists

4. Previous Intake Therapist Discontinuity Patterns at BYU Clients completed 115,567 OQ-45s before sessions 2 or more OQ-45s were available allowing evaluation of outcome among 12,190 clients Change from 1st to last OQ-45 was statistically reliable, F (12188) = 2474, p < .001 Change from 1st to last OQ-45 was, on average, also clinically significant There was no interaction effect, change from 1st to last OQ-45 did not differ from by group, F (1, 12188) < 1 J-T minimum recovery criterion

5. Previous Intake Therapist Discontinuity Patterns at BYU 8,423 clients who were assigned to treatment with a therapist other than their intake therapist (who experienced ITD) attended 106,214 sessions; Mdiscontinuity= 12.61 6,714 clients who continued in therapy with their intake therapist attended 71034 sessions; Mcontinuity= 10.58 Discontinuity clients attended significantly more sessions than continuity clients Mdiscontinuity= 12.61 vs. Mcontinuity= 10.58, t(15135) = 6.78, p < .001 two-tailed On average, treating discontinuity clients was 19.2% more expensive than treating continuity clients: 12.61 / 10.58 = 1.192

6. New System:3 + Years Without Intake Based on these findings, faculty voted to discontinue traditional intake beginning in January 2007, replacing intakes with initial sessions It is assumed that therapists begin psychotherapy during initial session Psychotherapy culture makes it difficult to change Trainees come ready to do intakes Our appointment and note keeping database system, Titanium, is pre-programmed with Intake Appointments Selection and referral functions are now performed based on questionnaires completed by clients seeking treatment The Clinical Director and Director of Training or members of the Clinical Management Team and Training Committee screen client questionnaires Obviously challenging clients are not assigned to inexperienced trainees Training committee members can assign to trainees seeking particular kinds of cases (couples, specific presenting problems) The past 3+ years constitute a quasi-experiment comparing use of formal intake with the assumption that therapists will keep clients

7. New System: Initial Therapist Discontinuity Patterns From 2007 to 2009 4,057 new clients entered individual psychotherapy 3,408 clients (84%) remained in therapy with their initial therapist for psychotherapy—continuity 649 clients (16%) met subsequently met with a different therapist for psychotherapy—discontinuity This discontinuity rate (16%) is significantly lower than the former rate (55.6%); χ2 (1, N = 19,194) = 2017.8, p < .001.

8. Comparing Previous and Current Outcome During the 6 years from 2004 to 2009 clients completed 86,454 OQ-45s 2 or more OQ-45s were available from 8,215 clients Change from 1st to last OQ-45 was statistically reliable, F (1, 8213) = 1367, p < .001 Change from 1st to last OQ-45 was, on average, also clinically significant There was, again, no interaction effect, change from 1st to last OQ-45 did not differ from by group, F (1, 8213) < 1 Treatment from 2007 to 2009 was as effective as treatment during 2004 to 2006 J-T minimum recovery criterion

9. Comparing Session Costs Across Years Session limits are not imposed, so a few long cases can skew session averages; cases from earlier years have lasted several years, creating skewed, larger averages Comparing sessions attended within one year of clients’ initial session created a fairer comparison (removing outliers) 5,367 clients treated from 2004 to 2006 attended 55,630 sessions during 12 months after intake, M = 10.37 individual sessions 5,307 clients treated from 2007 to 2009 attended 42,183 sessions during 12 months after initial session, M = 7.95 individual sessions t (10,672) = 14.1, p < .001 Treatment during 2007 to 2009 was 30% less expensive for individual psychotherapy sessions (10.37/7.95 = 1.3)

10. Conclusions For 3+ years, we have worked with the assumption that therapists will keep clients after their initial meeting This has happened for more than 80% of cases Outcome patterns, change from 1st to last OQ-45, did not differ when the intake system changed Individual psychotherapy sessions (costs from individual therapy) were reduced by 30%