de Jong, Kim

Delgadillo, Jaime

Lucock, Mike

University of Huddersfield Repository

University of Huddersfield RepositoryDelgadillo, Jaime, Lucock, Mike and de Jong, KimUsing outcome feedback in psychological therapy: a guideline for IAPT practitionersOriginal CitationDelgadillo, Jaime, Lucock, Mike and de Jong, Kim (2015) Using outcome feedback in psychological therapy: a guideline for IAPT practitioners. Other. University of York, York, UK. (Unpublished) This version is available at http://eprints.hud.ac.uk/31841/The University Repository is a digital collection of the research output of theUniversity, available on Open Access. Copyright and Moral Rights for the itemson this site are retained by the individual author and/or other copyright owners.Users may access full items free of charge; copies of full text items generallycan be reproduced, displayed or performed and given to third parties in anyformat or medium for personal research or study, educational or not­for­profitpurposes without prior permission or charge, provided:• The authors, title and full bibliographic details is credited in any copy;• A hyperlink and/or URL is included for the original metadata page; and• The content is not changed in any way.For more information, including our policy and submission procedure, pleasecontact the Repository Team at: E.mailbox@hud.ac.uk.http://eprints.hud.ac.uk/Using outcome feedback in psychological therapy: A guideline for IAPT practitionersJaime Delgadillo, Mike Lucock and Kim de Jong© University of York, University of Huddersfield and University of LeidenClinical Guide1A note about this bookletThis brief guideline was developed to support psychotherapists to adopt and use outcome feedback in English IAPT services. It was written as part ofa study supported by an NHS Research Capability Funding grant awarded by Leeds Community Healthcare NHS Trust in May 2015.For correspondence and to request permission to share, contact: jaime.delgadillo@nhs.netSuggested citation: Delgadillo, J., Lucock, M., de Jong, K. (2015). Using outcome feedback in psychological therapy: A guideline for IAPT practitioners. Department of Health Sciences, University of York: York.What is outcome feedback (OF)?• Outcome tracking technology helps to identify patients who are not progressing asexpected, and who may be at risk of poor outcomes.• Real-time feedback is provided to therapists and patients, indicating if therapy is ‘on track’or ‘not on track’.• This feedback informs the therapeutic process and plan.• Essentially, it’s a trouble-shooting aid that helps to improve outcomes.Introduction2Why do therapists need outcome feedback?• Although psychotherapy helps many people, it is also true that some patients don’t reliablyimprove and up to 10% of patients deteriorate.• Studies show that most therapists can’t predict treatment outcomes very accurately, andoften fail to detect deterioration in their patients. Especially if they mainly rely on theirclinical judgement, without reference to objective data or outcome measures.• This might be explained by the fact that many therapists tend to be over-optimistic abouttheir practice, looking for the ‘silver lining’ even in the most difficult cases.• Optimism is a good thing, and probably helps therapists to instil hope in many patients andto prevent burnout. However, over-optimism may not enable them to detect obstacles and totrouble-shoot early enough in some cases at risk of poor outcomes. According to theoutcome feedback method, these cases are referred to as risk ‘signal’ cases.Rationalehttps://www.psychotherapy.net/interview/preventing-treatment-failures-lamberthttp://onlinelibrary.wiley.com/doi/10.1002/jclp.20108/abstracthttp://onlinelibrary.wiley.com/doi/10.1002/cpp.656/abstracthttp://tcp.sagepub.com/content/34/3/341.shorthttp://psycnet.apa.org/journals/law/2/2/293/3Does outcome feedback improve outcomes?• Several trials published in the last decade show thattreatment outcomes can be improved if therapists use OFmethods. Most of this evidence comes from USA, althoughrecent European studies also show similar findings.• A meta-analysis of 6 major trials estimated that patientswho were classified as ‘not on track’ during treatment were2.3 times more likely to deteriorate in usual therapy, bycomparison to therapy + OF.• In published controlled trials, effect sizes favouring OFrange between d = 0.2 and d = 0.9.• Basically, OF helps to prevent deterioration.Evidencehttp://psycnet.apa.org/journals/ccp/78/3/298/http://www.tandfonline.com/doi/abs/10.1080/10503307.2013.871079http://www.tandfonline.com/doi/abs/10.1080/10503307.2014.928756http://www.tandfonline.com/doi/abs/10.3109/08039488.2012.736534Key Terminology:Cohen’s d = clinical effect sizes, where:+ is improvement – is deterioration0.20 = small; 0.5 = medium; >0.8 = largeOT = cases that are ‘On Track’NOT = cases that are ‘Not On Track’FbTP = Feedback to Therapist + PatientFbT = Feedback to Therapist onlyNFb = No Feedback (usual therapy)Effect of outcome feedback in short-term therapies (de Jong et al, 2014)4How do I make sense of outcome feedback?• Expected Treatment Response (ETR) models tell you how your patient’s progress compares to thatof (hundreds of) patients with similar characteristics, using depression (PHQ-9) and anxiety(GAD-7) measures.• ETR models include an upper and a lower boundary, which are like ‘confidence intervals’.• If symptoms are within the boundaries, therapy is likely to be generally ‘on track’ (OT) andprogressing as expected, since 80% of similar cases show symptom scores in this range.• If symptoms are above the upper boundary, this is a risk signal indicating that therapy is ‘not ontrack’ (NOT). The patient’s response is more like 10% of cases that deteriorate or don’t improve.• Scores below the lower boundary suggest remarkable improvement.• Also consider that reliable change (symptom reduction greater than 5 points) by session 4 can bea useful indicator of whether or not a patient is likely to respond and recover.Technologylower boundary80%upper boundary10%10%risk signal5How do I make sense of outcome feedback?• ETR models will help you to detect cases that are ‘not on track’ (NOT), so that you canreview progress, identify and overcome obstacles to improvement.• ETR models can also help you to learn about your own practice, and about therapyprocesses and mechanisms of change.InterpretationCase example: “Initially NOT, but responded after sudden gain”Actual graph from PCMIS system, for a patient with moderate OCD who accessed 18 sessions of CBTAnnotated graph to explain how to interpret itNOT during sessions 2 – 6Something important happened after session 6, which led to a sudden and reliable improvement, and points to a key process of changeEffortful practice of change methods and coping skills led to remarkable improvement between sessions 11 – 14Watch out for sudden spikes! This helped us to learn how to plan a successful relapse prevention strategyBooster sessions confirmed stability of improvement over time6Plausible obstacleshttp://eu.wiley.com/WileyCDA/WileyTitle/productCd-1118038207.html http://psycnet.apa.org/journals/pst/48/1/43/https://www.routledge.com/products/9780805857092 http://psycnet.apa.org/journals/pst/48/1/50/http://onlinelibrary.wiley.com/doi/10.1002/cpp.594/abstract http://psycnet.apa.org/journals/pst/48/1/58/http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0083875 http://psycnet.apa.org/journals/cou/54/1/32/http://bjp.rcpsych.org/content/early/2016/11/08/bjp.bp.116.189027 http://onlinelibrary.wiley.com/doi/10.1002/cpp.1977/fullhttp://www.sciencedirect.com/science/article/pii/S0005796716300249http://bjp.rcpsych.org/content/early/2015/11/05/bjp.bp.115.171017http://www.tandfonline.com/doi/abs/10.1080/10503307.2012.673023http://www.sciencedirect.com/science/article/pii/S0005796715000595http://www.sciencedirect.com/science/article/pii/S0005796714001387http://www.sciencedirect.com/science/article/pii/S0005796715300139http://psycnet.apa.org/journals/pst/50/1/88/http://espace.library.curtin.edu.au:80/R?func=dbin-jump-full&local_base=gen01-era02&object_id=200923Wider contextTherapy processesTherapist factorsPatient factors• Therapeutic alliance deficits or ruptures• Difficulties with empathy and/or positive regard in specific cases• Failure to promote expectancy• Motivational deficits, failure to promote readiness for change• All of the above get in the way of applying evidence-based change methods• Severe functional impairment• Comorbidity• Self-reported disability• Long-term medical conditions• Younger age (<20)• Minority ethnic status• Single (as opposed to married or cohabiting)• Personality disorder traits• Life problems and events that exacerbate psychopathology• Unemployment, socioeconomic deprivation• Lack of social support• Over-confidence• Over-reliance on intuition + neglect of external feedback• Coping deficits, low resilience• Tendency to avoid tackling problems directly• Lack of deliberate & disciplined practice to improve skills / performance7Why are some cases not on track?NOT signals could be due to one key barrier, or an interaction of multiple factors.What can I do to prevent deterioration?• A crucial aspect of using outcome feedback methods is tostrive to understand the possible causes of NOT signalsand (if possible) to minimise the impact of obstacles.• Some studies have successfully applied formal methodsknown as ‘clinical support tools’ to measure and addresskey obstacles related to:• therapeutic alliance (agreement on goals and tasks + quality of relational bond)• motivation (cognitive dissonance + expectancy + self-efficacy = readiness to change)• social support• external life eventsTrouble-shootinghttp://onlinelibrary.wiley.com/doi/10.1002/jclp.20109/pdfhttp://www.ncbi.nlm.nih.gov/pubmed/23656489http://www.ncbi.nlm.nih.gov/pubmed/23972415http://scholarsarchive.byu.edu/etd/1587/Clinical decision making strategy (Harmon et al, 2005)8TROUBLE-SHOOTING TIPSIf your patient is NOT, then:Check reliabilityAre scores consistent with other information? Did insight into symptoms cause change in self-reported scores? Are scores influenced by social desirability or secondary motives?Assess possible obstaclesWhich context, process, therapist or patient factors may be getting in the way of progress?Form hypothesesAre these factors modifiable? How could we try to influence these factors? If we modified this,what would we expect to see as a result?Make a planCan I set up a way to observe what happens before and after modifying potential obstacles? Ifthe obstacles are not modifiable, can we revisit and re-formulate our outcome expectations,therapy goals and tasks?Consider alternativesAugment treatment with medication? Multi-disciplinary care? Time to step-up or try a differenttreatment?Trouble-shootinghttp://psycnet.apa.org/journals/ccp/78/3/298/http://www.tandfonline.com/doi/abs/10.1080/14733140601140873http://psycnet.apa.org/journals/pst/52/2/185/http://psycnet.apa.org/journals/pst/52/2/180/Preventing deteriorationAlthough formal methods like ‘clinicalsupport tools’ can be useful, it is evident thatless complex methods are also effective. Forexample, research has shown that simplefeedback (just providing risk signals totherapists) can help to prevent deteriorationin NOT cases.This leads us to think that most therapistshave the skills and ability to formulate andmodify obstacles to therapeutic progress,but may just need a ‘nudge’ (risk signal) toactivate their trouble-shooting abilities.Nevertheless, informed by contemporaryliterature, we offer you a series ofsuggested steps and questions to consider(see tips on the left).We would encourage you to discuss thesesteps in clinical supervision.Useful references for clinical supervisors9Communicating feedbackTalking about outcome feedback• Introduce the rationale for OF as early aspossible (ideally at session 1), otherwisediscussing NOT signals can be difficultlater in therapy.• Review OF graphs with patients regularly• Discuss NOT cases in clinical supervision.Tips• Practice providing a rationale for OF and describing how to interpret graphs.• Use non-technical language, analogies (e.g. thermometer of distress, like weatherforecasts: expect certain temperatures at different seasons).• Use non-threatening language (Don’t say YOU’RE not on track), de-personalise NOTsignals, reframe as an opportunity to learn.• Use NOT signals as a prompt to explore obstacles in a collaborative way.• Print-out or e-mail OF graphs prior to therapy and/or clinical supervision sessions.10IMPLEMENTATION TIPSIf you find yourself avoiding or forgetting to discuss OF with your patients or supervisorThen:• Remind yourself that OF has improved patients’ well-being across several studies in several countries. Readreferences in pg. 4.• Ask yourself: does your intuition turn out to be correct all of the time? What’s the evidence?• Take some time to review the OF graphs of a handful of completed cases, you’ll be surprised how much you canlearn from this!• Practice or role-play what to say in preparation for OF discussions. Consider how to use metaphors andterminology that will make NOT feedback less daunting.• Seek advice from colleagues who use OF.• Bring time or organisational obstacles to the attention of managers. The service has a duty to make changes thatmay improve patient outcomes (IAPT key performance indicator 6).• Consider printing or e-mailing anonymised screen shots of feedback graphs to share them easily with patientsand supervisors.Making the most of feedbackhttp://www.tandfonline.com/doi/full/10.1080/10503307.2015.1051163http://www.tandfonline.com/doi/full/10.1080/10503307.2012.673023http://link.springer.com/article/10.1007/s10488-014-0589-6#/page-1http://www.tandfonline.com/doi/full/10.1080/10503307.2013.81769611

Using outcome feedback in psychological therapy: a guideline for IAPT practitioners

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