I wanted to let you know that we (Morten Anker, Jacqueline Sparks, and Ann Stapnes) just submitted the second of the Norway Feedback Project trilogy (a lofty title I know, but hey, I have to call it something notable to justify all this work). I can’t tell you much at this point until we get further along in the review and acceptance process. But I wanted to tell you a little about it because it is so interesting.
First, a little about the study: It analyzes 742 written client responses to 2 alliance oriented questions regarding the services received as part of a 6-month follow-up of couples in routine care. Using a qualitative method, 15 categories and 2 domains emerged. In addition, a quantitative analysis of respondents’ statements from the feedback study (Anker, Duncan, & Sparks, in press) compared feedback and non-feedback groups. The study’s mixed method provides a multi-layered view of couple therapy and the alliance, and an interesting finding emerged regarding couples’ experiences of an all but neglected part of the alliance—the nuts and bolts aspects of the agreement on tasks dimension. We generally think of agreement on tasks as being about the agreement of what models and techniques are used in service of the client’s goals. But the tasks dimension also includes routine tasks such as frequency of sessions, payment, scheduling, etc. Clients in the feedback condition had significantly fewer complaints regarding the more mundane aspects of the alliance: frequency of meeting, handling of cancellations and rescheduling, etc. These finding suggest that not only do we need to pay attention to these details, but also that somehow soliciting feedback resulted in more agreement about these mundane but apparently important aspects.
On another note, with Morten's help, I am interviewing the therapist from the Norway Feedback study that became the best therapist when feedback was added to her work. It is really fascinating. Here is the movie trailer version of what she has said so far: Feedback via the measures and graphs brought focus and clarity to the work; engendered a sense of shared responsibility and collaboration; and encouraged her to be more courageous, to step outside of comfort zones knowing that clients would let her know if she went too far. There is much embedded in those words, about the common factors and her development as a therapist, and I look forward to more from her.
The process with her, I believe, would be helpful for about anyone who takes their development as a therapist seriously--to reflect about what feedback has brought to the work, and how it has changed it for the better. That is a project that is just getting under way and I will let you know much more about in the fall.
The SRS, appreciation, and a call for therapist stories
I have thinking a lot about SRS scores and am very encouraged by what I have been seeing. I believe therapists are getting better and better at soliciting lower scores and feeling more comfortable with alliance feedback from clients. I believe we will see a downward trend of initial SRS scores in the overall data base as time goes on. Keep in mind that the SRS is the first real clinical use of an alliance measure, so as more and more therapists see the benefits, and more and more clients become part of the culture of feedback, the more the SRS will be used to generate alliance discussions. In the Norway study, based on all administrations of the SRS (2294), there was a mean of 34.8. Said another way, 51.8% scored 36 and higher, while 67.67% scored 34 and higher. The mean first session SRS was 33.4 And the SRS scores increased, on average, session by session. We are analyzing the data now and I'll keep you informed of our progress.
While I am talking about the alliance, I wanted to say a few words about "appreciation" because I think it is a very important concept and therapist action. It is essentially an expression of positive regard, another incredible idea that gets too little attention. This therapist quality is characterized as warm acceptance of the client’s experience without conditions. It is understood as a prizing, an affirmation, and a deep nonpossessive caring. Early research (e.g., Truax & Carkhuff, 1967; Orlinsky & Howard, 1978) was very supportive of the association between positive regard and outcome, with about two-thirds of the studies in the positive direction. Recent reviews, however, found that only 49% (27 of 55) of all associations were significant (Farber & Lane, 2002). When outcome and therapist positive regard were both rated by clients, however, the percentage of positive findings jumped to 88% (Farber & Lane, 2002). Let’s face it, that Carl Rogers guy was on to something.
Appreciation of clients is therefore a critical relational skill: appreciation of people in general, of their struggles, and of their humanity and innate goodness. I appreciate people and it shows, and I think it helps. In the new Heart and Soul, Norcross (2010, p. xx) concludes:
Clinically, the research results indicate that, first, the provision of positive regard or validation is strongly indicated in practice. Second, similar to empathy and the alliance, it is the client’s perspective of the therapist’s positive regard that has the strongest association with outcome. At the risk of redundancy, supportive therapists will privilege their client’s experience. Third, therapists cannot be merely content with feeling good about their clients, but should ensure that their positive feelings are communicated to them. This does not require a stream of compliments or an outpouring of love. Rather, it speaks to the need for therapists to communicate a caring, respectful attitude, affirming a client’s basic sense of worth (Duncan & Moynihan, 1994; Farber & Lane, 2002).
And finally, I have a project for any of you who fancy an opportunity to write about your therapy experiences. I started a new book that focuses a bit on therapist’s experiences and am looking for 2-3 page (double spaced) therapist stories about the use of feedback and how it has improved your work or developed you as a therapist. This could be about a particular client and how he or she specifically taught you to do good work in ways that you wouldn't have otherwise done, or how feedback over many clients has had a cumulative effect on your outcomes and perceptions about being a therapist. I am looking for evocative stories infused with your personal reflections that will both resonate with therapists and encourage them to take the risk to systematically solicit client feedback. Please change details about clients significantly to ensure confidentiality.
I will select several for inclusion, and the ones not selected will have another shot when Jackie and I do the next edition of Heroic Clients, Heroic Agencies. Thanks very much for your consideration. The deadline is June 15, so get crackin’.
After a year of contemplating and debating the best possible design and methodology for an RCT in a naturalistic setting, 2 years of intensive data collection, and a year and a half of data analysis, writing, and rewriting, the Norway Couple Feedback Study (Anker, Duncan, & Sparks, in press) has received final acceptance from what I consider to be one of the top (if not the top) psychotherapy research journals on the planet, the Journal of Consulting and Clinical Psychology. Hoorah! I want to publicly thank and congratulate my colleagues and very good friends, Morten Anker and Jackie Sparks not only for their dedicated efforts on the largest RCT ever done with couples, the first feedback study to address couples, and the first RCT published using the ORS and the SRS, but also for their spirit of collaboration and teamwork—that often not experienced stuff that really makes each person bring out their best and propel such a project to fruition.
While we cannot disseminate the article, I can now let you know more about the results. As most of you know, the study tested the effects of feedback in couples therapy compared with couples receiving treatment as usual (TAU) in a naturalistic setting (n=410). Consistent with our hypothesis, the feedback condition emerged as significantly superior to TAU. A moderate to large ES (0.50) was found for the feedback condition. The predicted score adjusted for severity of an average client in the feedback group was 4.89 points higher than an average client in the TAU group. The difference was, in effect, the difference required for reliable change. Said another way, the average post score for persons in the feedback condition (26.35) was nearly 5 points greater than the average post score for those in the TAU group (21.69). The difference between the groups, in other words, nearly constituted both a reliable change and transcended the clinical cut off. The proportion of clients responding to treatment in the TAU group was 41.7% (both in couple, 22.6%) and in the feedback group was 64.6% (both in couple, 50.5%). The strong effect of feedback seems particularly noteworthy given the relative simplicity of the intervention and in light of the comparison group being an active treatment.
In addition, the significant superiority of feedback over TAU was maintained at follow up. Moreover, the TAU group had a 34.2% separation/divorce rate v. 18.4% rate for the feedback condition. In the feedback group, 40.8% (both in couple) scored 25 or above and 5 or more points in change compared with 10.8% of non-feedback couples, a difference of nearly four times. Six month follow-up revealed that feedback maintained nearly a three-fold advantage in proportion of clinically significant change (35.7% v. 12.5%).
Another finding really blew us away—about therapist effects and feedback. The effect of feedback varied significantly across therapists, and was not due to outliers (extreme scores). The correlation between the variability in the effectiveness of a therapist with no feedback and variability in the effect of feedback was unusually high, r = -.99. Although the small number of therapists significantly limits any conclusions that can be drawn, it does suggest that the less effective therapists (those who had the worst outcomes without feedback) benefited more from feedback that the most effective therapists. Feedback, therefore, seems to act as a “leveler” among therapists, raising the effectiveness of lower or average therapists to that of their more successful colleagues. In fact, check this out: the therapist with the WORST results without feedback became the therapist with the BEST results with feedback! These preliminary findings based on but ten therapists warrant further investigation and replication. Nine of ten therapists benefited from the effects of feedback.
With this study in the bank, Jackie is writing a grant for replication with kids and families, and with Barry W. in Louisville, we are hoping to replicate in an inpatient setting.
Bottom Line: Add feedback to your work and watch your effectiveness soar!
The next Heart and Soul of Change conference is set: Heart and Soul 2010 will be in New Orleans, in the French Quarter, June 17-19, 2010. The conference will be held at the InterContinental Hotel (http://www.ichotelsgroup.com/intercontinental/en/gb/locations/neworleans) and I am very happy to say that the room rate was negotiated to be a very reasonable $119 per night. June 17 will be a pre-institute that covers the basics—I will do the morning, the client directed part while Scott will do the afternoon, the outcome informed part. That way, people should be starting off well grounded for the rest of the conference. You veteran CDOI’ers could skip the pre-institute, unless you are the kind of person who likes some repetition. I will be using new video but will be covering the common factors side of CDOI.
The rest of the conference boasts new material. The actual conference will run June 18-19, and as I said before will include the themes of “Recovery” and “Social Justice” with keynotes from speakers outside of CDOI, followed by a plenary of how these themes fit and complement CDOI. In the afternoons, the conference will include 3 separate tracks: Beginning/Intermediate (I will do the first day of this and Scott will do the second, so people just getting going can catch how to get started—we are offering it both days because with all the choices, it will allow folks to not miss a thing); Special Applications (this will include 3 breakout sessions covering a variety of special applications—these will be very pragmatic “how to” workshops, short on theory or repetition of CDOI concepts, except as they apply to the issue at hand, and long on practical considerations; and Implementation/Supervision/Administration, which will address agency implementation and training issues the first day and how to guide both supervision and overall management with the data on the second. Although we are in the early stages of planning, it is already shaping up to be an exciting three days. We are leaving ample time for lunch so that you may explore the amazing culinary experiences awaiting you in the French Quarter.
The Louisiana Counseling Association is our co-sponsor and they draw big numbers for their conferences. I did a keynote for them last year and was absolutely shocked to walk into a room with 800 people! That keynote led to this conference so there is already a lot of interest. This could bring a lot of new folks to CDOI so it is a great opportunity to spread the word. I hope you will consider coming. New Orleans is an incredible place to eat, drink, and be merry. Scott and I hope to see you there.
Heart and Soul 5 will be unlike any of the previous four in several respects. Scott and I felt that the conference needed to evolve. So in addtion to providing the latest and greatest information about the common factors and the power of feedback, we are integrating two themes, including keynote speakers from outside of the CDOI fold, into the conference: Recovery and Social Justice. Both themes connect well to CDOI work and the conference will highlight those connections. The recovery movement, as Bob B describes in his chapter in the Heart and Soul of Change 2nd ed, fits very closely with the values and practices of CDOI. We have always advocated for client privilege and just services, and see the ORS/SRS as a means to insure that social justice is more than a lofty idea. Using the ORS and SRS transcends notions of stereotypical cultural competence and promotes egalitarian practice--one that "levels" the therapeutic process, as Jackie has been writing about of late. Finally, for the first time we will offer a beginning/intermediate track for folks just getting acquaited with the ideas, a special population track looking at the broad applicability of CDOI practices, and a management/supervisor/implementation track for more advanced folks and those itching to implement on a large scale.
Just a brief update about Heart and Soul 2010: It will be in New Orleans—right in the French Quarter! Lousianna Counseling Association is the co-sponsor. I was there to look at the venues for the conference and it is such an historical, festive, musical, culinary, cultural place that you have to experience first hand to appreciate it. We are still negotiating with the hotels, but we will have a specific date this week some time (mid June 2010), which I will announce when I know. And good news, we are going to get a great deal so this will be, unbelievably, the most economical Heart and Soul to date. My experience last night on Bourbon Street only highlighted the fact that this is indeed a very fun place to visit.
Given I haven't been keeping my schedule up to date (I promise I'll do better), the good people at Spring Harbor asked me to announce that I will be in Portland, Maine on April 10 presenting: Becoming Outcome Informed: A Revolutionary Way to Improve Effectiveness
