Link between Outcomes & Worker-Client Relationship

1. Quick and Proven Waysfor Good Outcomes using Client FeedbackRebecca Codrington & David AllanRelationships Australia (NSW)rebeccac@ransw.org.au davida@ransw.org.au

2. Link between Outcomes & Worker-Client Relationship • Importance of worker-client relationship has been recognised for some time • How important is this relationship? • How do we measure it? • How can we use it to influence outcomes?

3. What Works in Therapy ?

4. What Works in Therapy Model 15% Cf. Hubble, Duncan & Miller, The Heart and Soul of Change: What Works in Therapy

5. What Works in Therapy Expectancy 15% Model 15% Cf. Hubble, Duncan & Miller, The Heart and Soul of Change: What Works in Therapy

6. What Works in Therapy Expectancy 15% Model 15% Client Factors 40% Cf. Hubble, Duncan & Miller, The Heart and Soul of Change: What Works in Therapy

7. What Works in Therapy Client Factors 40% • personality • contingencies: getting a job etc. • supportive family • and so forth

8. What Works in Therapy Expectancy 15% Model 15% Client Factors 40% Therapeutic Relationship 30% Cf. Hubble, Duncan & Miller, The Heart and Soul of Change: What Works in Therapy

9. What Works in Therapy Expectancy 15% Model 15% Client Factors 40% Therapeutic Relationship 30% Cf. Hubble, Duncan & Miller, The Heart and Soul of Change: What Works in Therapy

10. Worker-Client Relationship as a Construct “therapeutic alliance” = a construct that describes worker-client relationship Features: Bond = sense of liking and trust Goals = agreement on goals Tasks = collaboration on activities Bordin (1979)

11. Linking alliance with outcomes Past research with specific client groups particularly in context of therapy Strong link between alliance and outcomes with individuals in therapy Research now exploring other contexts (couples, families, young people, groups, casework)

12. What the literature says about OUTCOME • trajectory of change predictable • what happens early predictive of outcome: • positive change likely earlier than later • little change  risk of negative outcome • diminishing returns: • 60-65% clients symptomatic relief < 7 visits • 70-75% clients symptomatic relief < 6 months • 80-85% clients symptomatic relief < 1 year

13. Diminishing Returns

14. What the literature says about ALLIANCE BOND • Worker factors impact alliance • being open • flexible • warm unconditional positive regard • trustworthy • Client factors: • education level • being female • optimistic expectation • quality relationships outside of therapy

15. What the literature says about ALLIANCE cont.. GOALS • Consensus between worker and client TASKS • agreement between worker and client on techniques/methods Alliance will change over time  important to address disjunctions

16. How best to apply this? Useful to know part therapeutic alliance played getting outcomes (after the fact) BUT Moreuseful to know what is happening with the therapeutic alliance during the work

17. Feedback ‘Summative’ feedback (at the end) versus ‘Formative’ feedback (as you go) Get picture of what is happening with the therapeutic alliance (as you go) Then know how to use this in relation to outcomes (as you go)

18. How to measure outcomes? One extreme - just ask: How did we do? Did we achieve what was needed? Other extreme - questionnaires: Need to be ‘reliable’ Need to be ‘valid’  time consuming - several pages

19. example

20. How to measure therapeutic alliance? One extreme - just ask: How are you experiencing what we are doing? Other extreme - questionnaires: Need to be ‘reliable’ Need to be ‘valid’  time consuming - several pages

21. example

22. Reliable Valid Simple measures Miller & Duncan’s Outcome Measure: the Outcome Rating Scale [ORS] 1. Individual functioning (symptoms) 2. Interpersonal relationships 3. Socially – work adjustment, quality of life

23. Image of ORS

25. Outcome Measure Cut Off The most helpful index on the scale is the cut off Cut off for Adults = 25 Cut off for Adolescents = 28 Cut off for Children = 33

26. Cut off Points

27. Outcome Measure Cut Off

28. Understanding Client Scores • Below cut off - lower scores associated with earlier and larger changes • Above cut off (25-33%clients) more like people not seeking help • strengths based / specific problem solving approaches

29. Reliable Valid Simple measures Miller & Duncan’s Alliance Measure: the Session Rating Scale [SRS] 1. Relationship – based on clients expectations 2. Agreement on goals 3. Agreement on tasks / methods

32. Alliance Cut Off

33. What does this mean?

34. SRS Scores • High scores are not necessarily indicative of anything • Presence of positive relationship qualities not associated with outcome • ABSENCE of positive relationship qualities has a strong correlation with outcome

35. Teenagers ORS and SRS

36. Children (6-12) CORS & CSRS

37. Children (<6) YCORS / YCSRS

38. Groups GSRS

39. Free for individual use • Outcome Measures and Alliance Measures for adults, children, groups available from • http://heartandsoulofchange.com/measures/

40. Interpretation of Outcome Measure General trajectory of change highly predictable - the bulk of change happens sooner rather than later The longer the work continues, the more likely drop out and/or poorer outcomes

41. Alliance measure depends on Outcome measure

42. Alliance measure depends on Outcome measure cont..

43. Alliance measure depends on Outcome measure cont..

44. General If client outcomes score above cut-off and they have been sent by someone else Ask for and use: client’s view of the Referral Source’s score on measure to monitor and track progress

45. Outcomes with more than one person

46. Alliance with more than one person • SRS scales – used to monitor engagement • Opportunity to reach out to any one feeling excluded from the process

47. Positive but less predicative relationship between alliance and outcomes complexity multiple alliances alliance with parents vs alliance with young person more research needed Alliance and Outcome with Young People

48. Alliance and Outcome with Young People • Cognitive capabilities of children and young people • social cognitions • ceiling effect • importance of elements of alliance

49. Alliance and Outcome with Young People • Young people often non voluntary clients • do not acknowledge existence problems • goals different to referral source • increasing autonomy effect alliance • alliance even more important

50. Alliance and Outcome with Young People • Externalising vs Internalising Behaviours • Internalising stronger alliance, but less predicative of outcomes • Externalising harder to create alliance but more predicative of outcomes