Tipping an Organisation Upside down …. a work in progress…. Becoming a client directed and outcome informed organisation

Our Assumptions …. We all want the best outcomes for the people we work with / for We all want to use the resources we have to help as many people as possible We all value justice / fairness

Why Wesley Community Action opted for a Client Directed and Outcome Informed (CDOI) approach Values The research evidence Global change driving local reality

What is Client Directed and Outcome Informed (CDOI) ? Describes interactions where; –The clients voice is privileged –The worker purposefully forms a relationship based on the client’s Theory of Change –This work is informed by the client’s experience of the alliance and the outcomes

Factors accounting for successful outcome- Michael Lambert Spontaneous Remission Client/Extratheraputic Models/Techniques Placebo/Hope/Expectancy Common Factors Relationship

The Therapeutic Alliance Goals, Meaning or Purpose Means or Methods Clients view of the Therapeutic Relationship

The Research base? 9 Randomised Clinical Trials Over 1000 international studies and published articles

The largest study ever conducted on the treatment of problem drinking  Three different treatment approaches studied (CBT, 12-step, and Motivational Interviewing). Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK. Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal of Consulting and Clinical Psychology, 65(4), The client’s rating of the therapeutic alliance the best predictor of:  Treatment participation;  Drinking behavior during treatment;  Drinking at 12-month follow-up. Project MATCH The Alliance NO difference in outcome between approaches.NO difference in outcome between approaches.

 Considered to be the most sophisticated comparative clinical trial ever conducted  Four approaches (CBT, IPT, Drug, Placebo) Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46,  No difference in outcome between approaches. The client’s rating of the alliance at the second session, the best predictor of outcome across conditions. TDCRP The Alliance

How does it work 2 forms The first – Outcome Rating Scale – privileges the clients voice, promotes the clients Theory of Change and ensures transparency regarding agreed outcomes and monitoring of change The second- Session Rating Scale – measures the ‘fit’ between worker and client

The Outcome Rating Scale (ORS) Measuring Outcome Looking back over the last week, including today, help us understand how you have been feeling by rating how well 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) | | Interpersonally: (Family, close relationships) | | Socially: (Work, school, friendships) | | Overall: (General sense of well-being) | |

The Session Rating Scale (SRS) Measuring the Alliance Please rate today’s session by placing a hash mark on the line nearest to the description that best fits your experience. I did not feel heard, understood and respected We did not work on or talk about what I wanted to work on and talk about The therapist’s approach is not a good fit for me There was something missing in the session today I felt heard, understood and respected We worked on and talked about what I wanted to work on and talk about The therapist’s approach is a good fit for me Overall, today’s session was right for me Relationship: | | Goals and Topics: | | Approach or Method: | | Overall: | |

What are the implications for WCA in adopting a Client Directed Outcome Informed Approach ?

A Riddle - What is the difference between: –baking a cake; –sending a rocket to the moon; –raising a child?

Develop common ground, compromise or compete. Use experts to experiment and find the answers Learn by doing with clients and key people. Create stability. Follow the ‘best practice’ recipe.

Client led Complex Issues Feature Difficult to frame Multiple root causes Multiple stakeholders Emergent Unique Paradoxes, Dilemmas Response Good enough framing Cross boundary work Collaborative & Flat Adaptive Learning Customized Responses Transparent coping

“Living systems can only be disturbed never directed” Maturana and Varela And all organisations are living systems ( changing, sometimes messy, holding many truths)

Preconditions for Client Directed Approach - Wesley Community Action’s Journey St Lukes training – 2002 Intentional strength based practice – 2003 Leadership – confirming SB approach SB conference 2007 Palmerston North – presentation Dr Barry Duncan Visits by Barry in 2008,2009 and 2010 Leadership – confirming CDOI Data Management System Wesley Way 2011 – organisation practice framework.

The Wesley Way

How WCA implemented it.. Developing the frameworks that support this – an expectation of a culture of feedback Training and Supervision – Internal and external Water Cooler conversations – staff feeling OK with discomfort in using the tool Accepting Data as our friend – collecting and collating it

Client Voice

Is it really tipping the organisation upside?

YES We moving from an organisation where... Staff believe they actually change people. The organisation takes the credit for the hard work of the clients We blame the clients it they are not changing how we expect them to We design our systems as if clients are invisible or passive We ‘train’ clients how to be receivers of help.

To an Organisation where we.. understand that people only change when they intrinsically want to change and... create an environment conducive for people to do the right thing for them. Are great at spotting and celebrating positive changes made by clients Value regular honest feedback from clients