Utilizing Patient Feedback (and Therapist Civility) to Improve Psychotherapy Outcome Dan Buccino JHBMC JHUSOM BPI June 27, 2006

Civility and Healthcare  Through the 20 th Century, science has opened the body.  Into the 21 st Century, civility will reopen the person.  To do even better science.  Pro-civility practice and policies

Civility and Therapy  Good therapists born not made? =  Good manners come from a good heart.  Good therapists made not born? =  Good heart comes from good manners.  Legislating civility and public health? (NYC: quality of life, tobacco, obesity)  Teaching and Practicing “Relational Competence.”

Civility and Risk  Good relationship with pt and family best prevention against malpractice suit, even if adverse event.  Injured patients 50% less likely to sue when an error was disclosed and there was an apology. ( Annals Int. Med. 2004)  Move in OR & CO to make it illegal to use doctors’ apologies against them in court.  Acknowledge, apologize for outcome, not necessarily take blame.

Osler’s Golden Rule “Alter the Golden Rule: What you do not like when done to yourself, do not do to others.” - Sir William Osler, JHUSOM “Others bruise as easily as we do.”

One Step Beyond the Golden Rule! Think first of others’ (comfort and convenience). If not OK for others, don’t insist. Restrain Yourself! “presenteeism”

Updating the Wheel: Recent Research Treatment: 60% due to “Alliance” and Relationship (“common factors”: 8% of 13%) 30% due to “Allegiance” Factors (4/13%)30% due to “Allegiance” Factors (4/13%) 8% due to model and technique (1/13%) Extra-therapeuticExtra-therapeutic Wampold, B. (2001). The Great Psychotherapy Debate. New York: Lawrence Erlbaum.

Hubble, M., Duncan, B., & Miller, S. (1999). The Heart and Soul of Change. Washington, D.C.: APA Press Relationship Factors The Therapeutic Alliance:The Therapeutic Alliance: Agreement on goals;Agreement on goals; Agreement on tasks;Agreement on tasks; “Rogerian” core conditions.“Rogerian” core conditions. 60 %

(R+H+P) Formula for Success Practitioners’ Contributions: Relationship Hope and a Plan

Super Shrinks Do better than other therapists. Period. Regardless of caseload mix, severity, training, experience, degree, etc. Interpersonal facilitative skills (civility) best. Most open to feedback.

Therapy Effectiveness  Super Shrinks effective with 75%.  Least effective with 25%.  Improve least effective by 65% with active, formal patient feedback (re customer satisfaction, service, and outcome).  Least effective can then become effective with 41% of cases.  All therapy works sometimes with some patients.  What will work with this patient and this therapist at this time?

Scored to the nearest millimeter.Scored to the nearest millimeter. Add the four scales together for the total score.Add the four scales together for the total score. Client places a hash mark on the line.Client places a hash mark on the line. Each line 10 cm (100 mm) in length.Each line 10 cm (100 mm) in length. The Outcome Rating Scale

Scored to the nearest millimeter.Scored to the nearest millimeter. Add the four scales together for the total score.Add the four scales together for the total score. Client places a hash mark on the line.Client places a hash mark on the line. Each line 10 cm (100 mm) in length.Each line 10 cm (100 mm) in length. The Session Rating Scale

JHBMC Student Therapist Outcomes  9 students; passive collection of data  N=89 cases (n=75 ≥2 sessions)  Mean # sessions: 6.4  Mean intake ORS: 18.9  Mean D/C ORS: 25.1 (recovered ≥ 25 clinical cutoff)  Mean RCI: 6.2 (improved ≥ 5 points)

JHBMC Student Therapist Outcomes (cont’d)  48% improved (RCI ≥5) (36/75)  59% recovered (D/C ORS ≥25) (44/75)  86% of improved also recovered (31/36)  Preliminary data 6/26/06  Progress comes quickly. Tx is beginning of end.  Deterioration comes over time.

JHBMC Student Therapist Outcomes (cont’d)  Mean RCI with intake ORS < 25 (clinical cutoff) (72%, 54/75) : 9.7 (cf. 6.2)  More symptomatic populations improve more in tx.  61% (33/54) improve.  50% (27/54) recover.  Big improvements even without complete recovery.  Therapy works!

JHBMC Student Therapist Patient Satisfaction  9 students; passive collection of data  N=89 cases (n=75 ≥ 2 sessions)  Mean # sessions: 6.4  Mean intake SRS: 34  Mean D/C SRS: 35.6  Preliminary data 6/26/06

Thank You! Questions, comments, concerns? Dan Buccino

Counterintuitive Civility  It may be simple, but it’s not easy.  Common sense isn’t always common practice.  Changing surface changes depth.