A presentation by Dr. Rylie Moore presented on November 18, 2016 at the OAPA Annual Conference, titled: "Progress monitoring in therapy: On-going assessment of mental health symptoms and the therapeutic alliance". The presentation addresses how to measure progress in therapy and the importance of the therapeutic alliance.

1. Rylie Moore, Ph.D.
PROGRESS MONITORING IN
THERAPY:
Ontario Psychological Associate Association Conference
November 18, 2016
On-going assessment of mental health symptoms and
the therapeutic alliance

2. PROGRESS MONITORING
• What?
• Why?
• Purpose

3. • Pantheoretical
• Brief administration time
• Appropriate for use with specific patient population*
• Designed for routine administration
• Comprehensive
• Facilitates assessment and treatment planning
• Sensitive to clinically relevant change
• Information about psychometric properties
PROGRESS MONITORING
Important considerations
Overington & Ionita, 2012

4. • Clinicians will benefit from feedback when:
• Clinicians are committed to the goal of improving their
performance
• Clinicians are aware of discrepancies between the goal and
reality
• Feedback source is credible
• Feedback is immediate, frequent, systematic, cognitively
simple, and unambiguous
• Feedback provides concrete suggestions how to improve
PROGRESS MONITORING
Contextual Feedback Intervention Theory
Riemer & Bickman, 2004

5. 1. Symptoms
e.g., Depression, anxiety, sleep, substance use, self-harm,
emotional lability, psychosis, trauma, physical symptoms, pain,
etc.
2. Well-being
e.g., subjective well-being emotional distress, motivation,
satisfaction, life enjoyment, etc.
3. Functioning
e.g., work, school, intimate relationships, social, etc.
Assessment: Comprehensive tools
PROGRESS MONITORING

6. • Behaviour and symptom identification scale-24 (BASIS-
24; Eisen et al., 2004)
• Behavioral Health Measure-20 (BHM-20; Kopta &
Lowry, 2002)
• Clinical Outcomes in Routine Evaluation System-
outcome Management (CORE-OM; Barkham et al.,
1998)
• The Outcomes Questionnaire-45 (OQ-45; Lambert et
al., 1996)
Assessment: Comprehensive tools
See Overington & Ionita, 2012 for a review
PROGRESS MONITORING

7. • Depression
• BDI-II
• PHQ-9
• HPRSD
• Anxiety
• BAI
• OASIS
• GAD-7
• HADS
• Social Phobia Inventory
• Y-BOCS
• PTSD
• PCL-5
• Wellbeing
• WEMWBS
• Rosenberg SES
• Emotions/Affect
• PANAS
• Everyday Feeling
Questionnaire
Assessment: Specific tools
PROGRESS MONITORING

8. • Clinician Bias
• Tracking change over time
• Identify when clients are not progressing in
therapy
• Identify what is and is not working
• Change therapy; re-address goals
Benefits of progress monitoring
PROGRESS MONITORING

9. • Enhance outcomes
• Reactive self-monitoring
• therapist
• client
• PM measures can
• help accelerate client progress (De Jong et al.,
2014)
• shorten length of treatment (Whipple et al., 2003)
• reduce dropout (Whipple et al., 2003)
• reduce no-show rates (Bohanske & Franczak,
2010)
Benefits of progress monitoring
PROGRESS MONITORING

10. • Reese & Colleagues (2009): Client Feedback vs. TAU
• TAU group: 54% improved (RC); 13% deteriorated
• Feedback group: 80% improved; 4% deteriorated
• Reese & et al. (2009): Therapist Feedback vs TAU
• TAU group: 41% improved; 3% deteriorated
• Feedback group: 67% improved; 4% deteriorated
Research outcomes
PROGRESS MONITORING

11. • Lambert & Shimokawa (2011): meta-analysis of
not-on-track clients
• the average at-risk client whose therapist
received feedback was better off than
approximately 70% of at-risk clients in the no-
feedback condition
• When CST are used, feedback clients were
better off than 76% of the TAU clients.
Research outcomes
PROGRESS MONITORING

12. • Lambert et al. 2002: Feedback to therapists
Research outcomes
PROGRESS MONITORING

13. • Hawkins et al., 2004: Feedback to clients & therapists
• TAU (n = 64): 9% deteriorated, 22% RC, 10% CSC
• Therapist only (n = 70): 3% deteriorated, 30% RC, 10%
CSC
• Therap. & Client (n = 67): 5% deteriorated, 33% RC,
23% CSC
• Treatment non responders generally did not improve
with feedback, except in the therapist/client feedback
condition
Research outcomes
PROGRESS MONITORING

14. • De Jong et al., 2014: Feedback to clients & therapists
• supported previous findings; largest benefit for
treatment non responders
• Feedback more effective in dual feedback, rather than
to client-only
• Found benefit for short and long-term therapy
• Online format
Research outcomes
PROGRESS MONITORING

15. PROGRESS MONITORING
• Time efficient; client’s complete questionnaires
between sessions on their own time
• Easy/automatic scoring
• Results available to clinician & client
• Equivalent findings to paper/pencil research
(De Jong et al., 2014; Emmelkamp, 2005)
Benefits of online measurement

16. Hatfield & Ogles, 2004 p. 487
Practitioners cite, “adds too much paperwork”
and “takes too much times” as primary reason
not to progress monitor

17. PROGRESS MONITORING
• Consider cognitive limitations (dual diagnosis)
• CST should be validated for repeated
measurement/detecting change
• Be familiar with the relevant test manuals
• Decisions about treatment changes should not be
made solely on the basis of a measure, but should
include clinical judgement
Limitations

18. THERAPEUTIC ALLIANCE

19. THERAPEUTIC ALLIANCE
• Freud (1913) initially conceptualized TA as negative transference,
but later considered the possibility of a beneficial attachment
actually developing between therapist and patient (and not as a
projection)
• Zetzel (1956) defines the therapeutic alliance as a non-neurotic
and non-transferential relational component established between
patient and therapist
• Strupp (2001): positive feelings that arise in the patient – feelings
which can lead to the creation of a positive therapeutic climate
from an emotional and interpersonal perspective
What is it?

20. • Rogers (1951) defines the active components in
the therapeutic relationship as empathy,
congruence, and unconditional positive regard
• Bordin (1979) defines TA as a collaborative
relationship that consists of three essential
elements:
• agreement on goals
• agreement on tasks
• a personal bond made up of positive feelings
THERAPEUTIC ALLIANCE
What is it?

21. • Research about common factor associated with
therapy; non-specific factor (Strupp, 2001)
• Corrective emotional experience
• Attachment
• Re-ogranize insecure attachment bonds in
adulthood
• Relational template for future relationships
THERAPEUTIC ALLIANCE
Why is it important?

22. • Penn Scales (Alexander et al., 1986)
• Vanderbilt Scales (Hartley & Strupp, 1983)
• Toronto Scales (Marziali, 1984)
• Working Alliance Inventory (WAI; Horvath &
Greenberg, 1986, 1989)
• California Scales (Gaston & Marmar, 1994)
• Therapeutic Session Report (Orlinsky & Howard,
1986)
THERAPEUTIC ALLIANCE
Measurement tools
See Ardito & Rabellino, 2011 for a review

23. • Issues with progress monitoring
• Discussing negative feedback
• Discussing difficult questions
• e.g., I believe my therapist likes me
• e.g., I am confident in my therapist’s ability to
help me
• Differing perspectives between therapist and
client
THERAPEUTIC ALLIANCE
Measurement tools

24. • What is a rupture?
• Episodes of tension or breakdown in the
collaborative relationship between patient and
therapist (Safran et al., 2011)
• Deteriorations in the relationship between the
client and therapist. (Horvath & Greenberg,
1989).
THERAPEUTIC ALLIANCE
Repairing Ruptures

25. • Recognizing when a rupture has occurred
• Markers of client behaviours
• Subtle misunderstandings
• Withdrawal
• Disagreement
• Progress Monitoring
THERAPEUTIC ALLIANCE
Repairing Ruptures
Horvath & Greenberg (1989)

26. • How to repair
• Acknowledgement
• Negotiation
• Explore parallel situations
• Consensus
• Develop alternative ways of managing similar
situations
THERAPEUTIC ALLIANCE
Repairing Ruptures
Horvath & Greenberg (1989)

27. THERAPEUTIC ALLIANCE
• Fenton et al. (2001) found 6 measures to be strong
predictors of outcomes; none were stronger than
another
• strong alliances predicted positive outcomes
• Safran et al. (1990) concluded that outcomes were more
closely related to successful resolution of ruptures
• Horvath & Symonds (1991) found early ratings of TA
were more predictive of outcomes
Research & benefits of on-going measurement

28. • Tracey (1989), the more successful the
outcome, the more curvilinear the pattern of
client and therapist session satisfaction
(high–low–high) over the course of
treatment.
• Stiles et al. (2004) found V-shaped alliance
patterns may be correlated with positive
outcomes.
THERAPEUTIC ALLIANCE
Research & benefits of on-going measurement

29. • Progress monitoring of the TA allows for immediate
feedback about the relationship
• Immediate interventions
• Repair ruptures sooner and more quickly
• Promotes positive framework for feedback in other
relationships
• Enhances self-awareness and assertiveness
THERAPEUTIC ALLIANCE
Research & benefits of on-going measurement

30. BRINGING IT ALL
TOGETHER• Progress monitoring enhances client outcomes,
especially for client’s who may not be responding to
treatment
• Online progress monitoring is equivalent to
paper/pencil measurement & minimizes perceived
limitations
• TA research demonstrates variable changes to
alliance; progress monitoring allows for feedback
about when to repair ruptures

31. END
Questions?