Becoming Client Directed and Outcome Informed (CDOI)

by Colleen Gray

Therapists are increasingly facing calls to demonstrate that the therapeutic services which they are funded to provide do indeed help clients to achieve desired changes and improved quality of life. These calls for accountability are a worldwide phenomenon.

Funding bodies and clients are insisting that to be paid, therapists and the systems of care in which they operate must “deliver the goods”. The consumers of our services are demanding results.

Accountability is the watchword of the day and “return on investment” the guiding metric. Like it or not, psychotherapy has become a commodity. Those footing the bill want proof of the effectiveness and value of the psychotherapy services they are purchasing.
(Miller and Duncan)

In August this year, I was privileged to attend the inaugural and intensive “Train The Trainer” conference on Client Directed and Outcome Informed (CDOI) approaches in Chicago. Dr Scott Miller and Dr Barry Duncan from the Institute for the Study of therapeutic Change are leading the revolution to improve therapy effectiveness using the CDOI approach. My encounter with them reminded me of the reasons I was initially attracted to the world of therapy; namely, to do good work and make a difference to my own and other people’s lives.

The research and discussions we shared during the week were both simple and profound. There was a humbling emphasis on the research which shows that it is the client that makes the therapy work, rather than the therapist. When the voice of the client is privileged and placed at the centre of the therapeutic process, their theory of what caused the problem and what needs to change can inform the therapeutic process. Several recent studies have documented significant improvements in both retention in and outcome from treatment when therapists access and utilise client feedback about the progress and outcomes of therapy.

Traditionally, the role of the therapist has been that of an expert who is endowed with superior knowledge and skill which he/she uses to fix the client. Today, as we embrace new understandings about what makes therapy work, this widely held notion is losing its appeal and validity.

Therapy is at a crossroads; research consistently demonstrates that the possession of extensive training and skills in the various medical and therapeutic models (there are currently over 400) does not guarantee that clients will receive effective therapy. Rather client perceptions of a positive relationship with the therapist account for 30 percent of successful outcomes (Asay & Lambert, 1999), and their views of the alliance account for as much 54 percent of therapeutic gains (Wampold, 2001).

Influencing the client’s perceptions of the alliance is the most direct impact we can have on change and improved client outcomes.

Miller and Duncan’s vision of relational therapy, as opposed to a medical model of therapy, better suits the CDOI approach than theory driven methods. The CDOI approach is more effective than so called ‘competent service delivery systems’ which rely on infrastructure, policies and formulae procedures which treat clients according to the therapist’s diagnosis or perceived deficits.

Clients are so much more than their problems: substance abuse, abuse victims and cases of depression are only labels, and no one label fits the individual experiences of people who experience distress from these issues.

Clients are unique people who possess beliefs and theories about their issues and what they need to solve them. Although many therapists understand the need to provide client-centered care and utilise the client’s innate skills and resources, many are unclear about how to actually work with clients in this way. Too often they reformulate the client’s problem to fit into their own particular mode of therapy. Behaviour therapists will work with behavioral problems, addiction specialists will work with addictive behaviour, etc. Implementing CDOI therapy is easier said than done.

Client Directed Outcome Informed Approaches

Over the last seven years, Miller and Duncan have been working to develop a valid, reliable, and feasible system for measuring psychotherapy treatment outcomes. They have called this the Client Directed Outcome Informed (CDOI) approach.

They espouse a number of benefits from using the CDOI approach, including its ability to measure the effectiveness of therapy from the client’s perspective.

As an accountable service delivery system, the CDOI approach claims to:

• Improve service efficiency;
• Reduce the numbers of ‘no show’ clients;
• Reduce budget expenditure on unnecessary services;
• Inform on clients’ progress during the treatment period;
• Measure the effectiveness of therapy and adapt it to suit clients’ needs.

Any interaction with a client is considered to be CDOI when the client’s voice in therapy is privileged and the therapist purposefully forms a strong partnership with that client. The therapist’s intention is:

• to enhance the client factors that account for successful outcomes;
• to present a variety of possible theories that could best achieve successful outcomes;
• to use the client preferences/theories to guide choice of technique;
• to inform the work with reliable and valid measures of the client’s experience of the alliance and outcome.

This approach is solidly supported by 40 years of data and research which consistently shows that:

• The quality of the therapist/client relationship is a more potent predictor of outcome than the theoretical orientation, experience level or professional discipline of the therapist;
• Client perception of the relationship is a better predictor of outcome than the therapist’s perception;
• There is no correlation between the length of time spent in therapy and the strength of the alliance;
• Therapists aren’t always aware when their perceptions of the therapeutic alliance are at odds with those of their clients;
• Congruence between client’s pre-existing pretreatment beliefs about their problems and the therapist’s approach results in better treatment outcomes;
• Poor therapeutic alliances account for client drop-out rates of up to 50 percent in some services;
• Therapists with better outcomes cost their clients less money.

The days of therapists taking credit when therapy works and blaming the client when it doesn’t appear to be over. Clients are awake to the inadequacies of therapists, and on the whole are unimpressed by specific technical interventions.

Tools for Becoming Outcome Informed

Because no user-friendly measures for evaluating the outcomes of psychotherapy previously existed, Miller and Duncan developed the Outcome Rating Scale (ORS) and Session Rating Scale (SRS), both of which are brief and easy to use, and provide a feasible alternative to other, lengthier evaluation forms.

The ORS is rated at the beginning of the session to measure the client’s functioning in the areas of individual, relational and social. In ongoing sessions, comparisons between the scores show the progress of therapy. If positive changes occur in these three areas, it is widely considered to be a valid indicator of successful treatment outcome (Lambert, 1996). If no progress occurs after three to six sessions, other options for therapy are discussed, including a review of the therapy goals, the therapeutic alliance and possible referral. Here is an example of the questionnaire.

The Outcome Rating Scale

Looking back over the last week (or since your last visit), including today, help us understand how you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels.

Individually:
(Personal well-being)

I----------------------------------------------------------------------I

Interpersonally:
(Family, close relationships)

I----------------------------------------------------------------------I

Socially:
(Work, School, Friendships)

I----------------------------------------------------------------------I

Overall:
(General sense of well-being)

I----------------------------------------------------------------------I

Institute for the Study of Therapeutic Change

Session Rating Scale (SRS)
The SRS is rated at the end of each session and provides feedback about whether or not the client’s expectations and desired outcomes were met. This scale provides an on-the-spot assessment to detect if there are any areas of weakness or misalliance, and the client feedback informs the therapist about what changes need to made.

Relationship:
I-------------------------------------------------------------------------I

Goals and Topics:

I------------------------------------------------------------------------I

Approach or Method:

I-------------------------------------------------------------------------I

Overall:

I------------------------------------------------------------------------I

Institute for the Study of Therapeutic Change

Administration and Scoring Systems
Accountability is assured from the information that these rating scales provide. Individual therapists can track the outcomes by recording the ratings on a paper based system.

A.S.I.S.T
Miller and Duncan have developed a computerized, Administration, Scoring, Interpretation, and data Storage Tool for the Outcome Rating Scale (ORS) and Session Rating Scale (SRS)

Individuals and agencies are able to purchase the computer based program called A.S.I.S.T. to monitor the outcomes of client sessions. Individual and network versions of this program have recently been released.

Are you looking for a simple, valid, reliable and automated way to monitor and improve the outcome of you clinical work? The ASIST program is a easy to use, end-user software program that administers, scores, interprets, and stores scores from the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS). ASIST also provides therapists with "real time" feedback regarding their client's experience of the alliance and progress in treatment. Using a sophisticated set of algorithms based on years of research and a large normative sample, the program helps clinicians identify clients who are making progress and those "at risk" for a negative outcome or drop out.

Becoming Outcome Informed and using these tracking systems provides therapists with instant and ongoing information about what is and isn’t working, so that changes to therapy can be made as they are needed.

Recent studies show improved cost effectiveness for therapists which use CDOI. In a study of 2100 clients at a community mental health centre, the CDOI service delivery system was found to have:

• Decreased average number of sessions by 40%
• Decreased dropouts by 40%
• Decreased no-shows by 50%
• Decreased long-term null outcomes cases by 80%
• Saved a total cost estimated at $494,600 (Miller and Duncan, 2006)

In the era of therapy accountability and economic rationalism, such results bear close scrutiny and are not to be sneezed at.

There is a growing worldwide movement, both private and governmental, to involve consumers in mental health care and improve the outcome or value of rendered services. CDOI delivery systems are a natural fit for this paradigm shift in mental health services.

This has been a brief overview of the week’s learning. I look forward to assisting any agencies who are seeking training or further information on CDOI approaches.

I urge you to visit the website of Dr Scott Miller and Dr Barry Duncan and access the generous resources they provide. The address is www.talkingcure.com.