Monitoring in
family therapy
How to stay loyal to our dialogical values?
Karine Van Tricht, Peter Rober & Rolf Sundet
2nd 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 Sundet
Leuven, 2013
rosundet@online.no
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 Money
o Results
o Social benefit
• Psychotherapy
o Evidence based
o Effective
o Efficient
• ‘To measure is to know’ atmosphere
• Quality Control Systems
From Evidence Based Practice to
Practice Based Evidence
• RCT’s & Psychotherapy
o
o
o
o
Specificity & complexity
Generalizability?
External validity?
Creativity?
• RCT’s & Family Therapy = trouble in paradise
o What is the diagnosis?
o Complexity and specificity of treatment
o Who/what is responsible for change?
Monitoring: bridging the gap between
research and practice
• Terminology
o
o
o
o
o
o
o
o
o
Outcome management
Routine Outcome Monitoring
Routine Outcome Measurement
Feedback Oriented therapy
Client Directed Outcome Informed Therapy
Tracking
Monitoring
ROMMEN
QITTEN
Evidence
• Outcome improvement
o
o
o
o
Duncan & Sparks, 2009; 2010
Reese et al., 2010
Anker, Duncan & Sparks, 2009
Duncan & Miller, 2000
• Drop-out prevention & better dose/effect ratio
o Lambert, 2007; 2010
• Experienced as useful and helpful
o Anker et al., 2011
• Leading to a better working alliance
o Sundet 2010; 2011; 2012
Monitoring as a way of working
together
Creating
Feedback
Go with
the flow
Dialogical
space /
Culture of
feedback
New way
of
understan
ding
Van Tricht & Rober
Integrating
feedback
Sources of inspiration (1)
Client
System
Therapist
System
Socially, cultural,
religious, spiritual
Social (work,
education, social
contacts)
The room of the
therapist as a
dialogical space in
which a multitude of
stories, opinions,
emotions and
perspectives come
together
Van Tricht, Van den Broeck, Rober,
2011; Rober 2012
Family, close
friends
Therapist(s),
couple, parents,
children
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
relevant
User friendly
Easily available
Stinckens, Smits, Rober & Claes, 2012
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 conclusion
The 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
To
focus
To
structure
To
explore
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
Conceptual Framework QIT Family
Van Tricht & Rober
Specificity of integrating monitoring in
Family Therapy
• Instrumental level
o Adult & child versions
o Outcome & process
• Implementational level
o
o
o
o
Clear introduction
In session: Apart / together
Home work: Apart / together
On paper or electronic
• Dialogical level
o Open, curious, interested and non-judgmental T attitude
o Feedbackloops: how, what, when
o 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)
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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
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•
•
•
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 outcome
o 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 therapist
o Relational (im)balances
• split alliances/siding/moving toward equilibrium
Muran & Barber, 2010
“An emerging quality of collaboration in relation to the
necessary accomplishments, arising from a web of
interacting relational dynamics”
Muran & Barber, 2010
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
Publications
Sundet, 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).