Monitoring in family therapyHow to stay loyal to our dialogical
values?
Karine Van Tricht, Peter Rober & Rolf Sundet2nd Congress of the Open Network for Dialogical Practices
7-9 March 2013 Leuven, Belgium
Measure of process and outcome as conversational tools: Pathways to a
dialogical oriented practice of service user and therapist collaboration.
Rolf SundetLeuven, 2013
University College of Buskerud,Institute for Research in Mental Health and Substance Abuse
&The Ambulant Family Section, Dept of Mental Health for Children and
Adolescents, Hospital of Drammen, Vestre Viken HF.
Mental Health Care anno 2013
• Neoliberal society – Market economy• Economic product• Profitability
o Moneyo Resultso Social benefit
• Psychotherapyo Evidence basedo Effectiveo Efficient
• ‘To measure is to know’ atmosphere• Quality Control Systems
From Evidence Based Practice to Practice Based Evidence
• RCT’s & Psychotherapyo Specificity & complexityo Generalizability?o External validity?o Creativity?
• RCT’s & Family Therapy = trouble in paradiseo What is the diagnosis?o Complexity and specificity of treatmento Who/what is responsible for change?
Monitoring: bridging the gap between research and practice
• Terminologyo Outcome managemento Routine Outcome Monitoringo Routine Outcome Measuremento Feedback Oriented therapyo Client Directed Outcome Informed Therapyo Trackingo Monitoringo ROMMENo QITTEN
Evidence• Outcome improvement
o Duncan & Sparks, 2009; 2010o Reese et al., 2010o Anker, Duncan & Sparks, 2009o Duncan & Miller, 2000
• Drop-out prevention & better dose/effect ratioo Lambert, 2007; 2010
• Experienced as useful and helpfulo Anker et al., 2011
• Leading to a better working allianceo Sundet 2010; 2011; 2012
Van Tricht & Rober
Monitoring as a way of working together
Dialogical space /
Culture of feedback
Creating Feedbac
k
Integrating
feedback
New way of
understanding
Go with the flow
Socially, cultural, religious, spiritual
Social (work, education, social contacts)
Family, close friends
Therapist(s), couple, parents,
children
The room of the therapist as a dialogical space in which a multitude of stories, opinions, emotions and perspectives come together
ClientSystem
Therapist System
Sources of inspiration (1)
Van Tricht, Van den Broeck, Rober, 2011; Rober 2012
Stinckens, Smits, Rober & Claes, 2012
Sources of inspiration (2)
• QIT online (Quality Improvement in Therapy)
Basic Principles
Characteristics
Instruments
Practice based Multidimensional
Psychometrics
Process oriented
Multimodal A-theoretical
Feedback driven
Flexibel Change sensitive
Broad spectrum
Internetbased Clinically relevantUser friendlyEasily available
A qualitative study of a locally developed family based practice
within Mental Health for Children and Adolescents
Conclusions: Two measures, the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS):
• They function as intended, that is; as tools of feedback.• A surplus: They function as conversational tools, that
is; they give rise and opportunity to conservational types and processes
Repairing an alliance burst by means of discussing feedback
Clinical conclusionThe ORS and the SRS do not give
answers, they are opportunities for questions
The family perspective:
The function of ORS & SRS as conversational
tools
To communicate
Tofocus
Tostructure
Toexplore
To tell and express
To visualize
To give direction to the work
To discover
To state areas of acceptance and change
To make distinct
To state thematic content
To deepen
The Therapist Perspective: The Function of ORS and SRS
as conversational tools
The scales as openings
...for conversations about feedback, progression and change...for conversations that express experiences, meanings, and perspectives about the therapeutic work...for conversations that create routine and structure...for conversations characterized by the not-knowing position...for externalizing conversations
...for conversations that bring forth a product or result
Van Tricht & Rober
Conceptual Framework QIT Family
Specificity of integrating monitoring in Family Therapy
• Instrumental levelo Adult & child versionso Outcome & process
• Implementational levelo Clear introduction o In session: Apart / togethero Home work: Apart / togethero On paper or electronic
• Dialogical levelo Open, curious, interested and non-judgmental T attitudeo Feedbackloops: how, what, wheno Enactment
Measurements of QIT Family [Informed Consent (Van Tricht & Rober, 2013)] Concerns Questionnaire (Van Tricht & Rober, 2013) SCORE-15 (Fay e.a., 2012; Stratton, subm. in JFT) OQ-45 (Lambert e.a., 1996) YOQ-30.2 (Burlingame & Lambert, 2001) ORS (Duncan & Miller, 2000) SRS (Duncan & Miller, 2000) (Y)CORS (Duncan, Miller & Sparks, 2003) (Y)CSRS (Duncan, Miller & Sparks, 2003) TSS(Kokotovic & Tracey, 1990; Tracey, 1989;
Hafkenscheid, 2012) IMI(Kiesler, 1996; Hafkenscheid, 2012)
Van Tricht & Rober
Feedback CULTURE In the relationship between service user and therapist, the
therapist perspective must be transparent and the service users perspective is given priority, especially in situations of no change or detrimental development
In the relationship between management and therapists the perspective of managers must be transparent and the therapist perspective must be given priority in each actual case.
The function of feedback is dependent upon allowing the therapists clinical autonomy in order to respond in a tailored manner to the feedback from the service users.
These measures are in danger of being ruined as feedback and conversational tools if they are included in a culture of competition and control
Thank you!
Alliances in Couple Therapy
• How to define the alliance in systemic therapies?• Dyadic relations / additional information?• Clinical relevance when there’s so much
confusion?• Overall conclusion:
o Positive correlation between working alliance and successful outcomeo Adding one more person adds multiple relationships
Muran & Barber, 2010
Alliances in Couple Therapy
• Individual model of the alliance + relational dynamics (Couple Alliance Scale, Pinsof & Catherall, 1984)o Alliances between each client and the therapist
• Direct self-reported alliance• Inferred alliance (guesses of the qual. & strenght of the partners’
rel. T)o Alliance between ‘clients-as-a-couple’ and the therapisto Relational (im)balances
• split alliances/siding/moving toward equilibrium
Muran & Barber, 2010
Muran & Barber, 2010
“An emerging quality of collaboration in
relation to the necessary accomplishments,
arising from a web of interacting relational
dynamics”
Gender
Gender
Motivation
Power Gender
Enactment
A Dialogically ORIENTED PRACTICE• including the voice, perspective, idea of the
other, that is; difference is included in the dialogical.
• to respond to the other and be responded by the other.
• to be embodied and embedded in social practices, that is; working with and in emotional transport and relational action
The practice• The use of conversational tools and the weight on
dialogue gives rise to a practice where reflection and meaning making are intertwined with emotional and experiential participation of the therapist
• The centrality of collaboration
Collaboration
Collaboration is characterized by;
Mutualism (turn-taking, jointly responding to the other’s response, dialogue, conversation)
Common goal Putting difference to work
Family based practice
”The helpful relationship”
”The helpful participation”
”The helpful conversation”
Generating collaboration (Alliance and to listen, take seriously and believe)
Using professional knowledge
Asking questions, giving time and structure the work
Giving of oneself Understanding through participation
Reformulation
Fighting violation, disparagement and degradation
Having many possibilities
Giving and receiving feedback
PublicationsSundet, R. (2010). Therapeutic collaboration and formalized feedback: Using perspectives from
Vygotsky and Bakhtin to shed light on practices in a family therapy unit, Clinical Child
Psychology and Psychiatry, 15(1), 81-95
Sundet, R. (2011). Collaboration: Family and therapists perspectives of helpful therapy. Journal of
Marital and Family Therapy, 37(2), 236-249
Sundet, R. (2012). Therapist perspectives on the use of feedback on process and outcome: Patient
focused research in practice. Canadian Psychology, 53(2), 122-130
Sundet, R (2012). Patient focused research supported practices in an intensive family therapy unit:
What happens? Journal of Family Therapy, (Accepted for publication).
Sundet, R. (2012). Postmodern-oriented practices and implementation of patient-focused research:
Possibilities and hazards. Australian and New Zealand Journal of Family Therapy (In review).