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Client-Directed Outcome-Informed Clinical Work

Frequently Asked Questions

Compiled by Cynthia Maeschalck, MA, Certified Trainer

http://www.talkingcure.com/training.asp?id=200

The FAQ page is broken down into seven categories of questions:

1. The basics of client-directed, outcome-informed (CDOI) clinical work
2. The Outcome and Session Rating Scales
3. Interpretation and scoring
4. Application of CDOI in clinical practice
5. CDOI in specialized settings and populations
6. CDOI Myths
7. CDOI data management

These categories cover a broad array of questions about CDOI however there are hundreds of possible questions regarding the nuances of CDOI. Therefore, suggestions on additional resources are referenced throughout the FAQ page.

It is very possible that your question has been asked and answered before so be sure to read through the lists provided. If you are unable to find the answer to your question, we suggest that you join the Heroic Agencies (HA) list serve. The HA list includes over 700 members worldwide who are interested in or are implementing CDOI practices in their work. The HA list is a great resource where you can get input on questions you have about CDOI from the co-directors, associates, certified trainers of the Institute for the Study of Therapeutic Change (ISTC) and CDOI practitioners worldwide. Join athttp://www.talkingcure.com/reference.asp?id=71

CDOI basics:

What is CDOI and where did CDOI originate?

Developed by the co-directors of the Institute for the Study of Therapeutic Change (ISTC), CDOI is an empirically-based meta-theory that at its center is based on the idea that client feedback can both improve effectiveness and enable services to be individually tailored. After a trial and error struggle with existing measures and reaching the conclusion that any method must be feasible as well as reliable and valid, Barry Duncan and Scott Miller developed the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) (building on the work of Lynn Johnson) as clinical tools to encourage therapists to openly discuss the benefit and fit of services with clients. During that time, Jacqueline Sparks (now an associate of ISTC) became involved and ultimately collaborated on Heroic Clients, Heroic Agencies, as well as many other projects (e.g., the dangers of psychiatric drugs for children) including the development and validation of the child measures and The Heroic Client revised edition.

CDOI service contains no fixed techniques and no causal theory regarding the concerns that bring people to therapy or substance abuse treatment. Any interaction with a client can be client-directed and outcome-informed when the consumer’s voice is privileged,  recovery is expected, and helpers purposefully form strong partnerships with clients: (1) to enhance the factors across theories that account for successful outcome; (2) to use the client’s ideas and preferences (theory of change) to guide choice of technique and model; and (3) to inform the work with reliable and valid measures of the consumer’s experience of the alliance and outcome.

Download a free description of CDOI (The CDOI Fact Sheet) athttp://www.talkingcure.com/reference.asp?id=66 To learn more about CDOI we recommend that you read Heroic Client,(Duncan, Miller and Sparks, 2004) available athttp://www.talkingcure.com/bookstore.asp?id=226 or Heroic Clients, Heroic Agencies (Duncan & Sparks, 2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57

What does PCOMS stand for and where did the term come from?

PCOMS stands for Partners for Change Outcome Management System. Devoted to empirically-derived clinical practices, the co-directors of the Institute for the Study of Therapeutic change (ISTC) developed PCOMS by incorporating the most robust predictors of therapeutic success into an outcome management system that truly partners with clients while honoring the daily pressures of front-line clinicians. Unlike other methods of measuring outcome, this system truly gives clients the voice they deserve and assigns consumers key roles in determining how services are both delivered and funded. PCOMS was launched by Scott Miller and Barry Duncan after 7 years of development, research, and publication in peer reviewed journals. PCOMS is now available in a web-based application (www.MyOutcomes.com ). PCOMS provides a reliable, valid, and feasible feedback process that has been shown to significantly improve effectiveness and efficiency in real clinical settings. To learn more about PCOMS, read The Outcome and Session Rating Scales: Administration and Scoring Manual (Miller and Duncan August 2004 revised edition)http://www.talkingcure.com/bookstore.asp?id=226 or the free article “The Partners for Change Outcome Management System” athttp://www.talkingcure.com/reference.asp?id=66 Also download a free description of CDOI (The CDOI Fact Sheet) athttp://www.talkingcure.com/reference.asp?id=66

How does CDOI fit with the approach and/or the scales I am already using?

Any therapeutic model or approach can be used with CDOI work. CDOI involves eliciting feedback from clients regarding the fit and effectiveness of the approach used. The key difference for practitioners incorporating CDOI work is that if a particular model/ technique or therapist is not a good fit for a client and/or is not resulting in any positive change for the client, then another treatment model or a different therapist would be sought; one that was a better fit for the client that will hopefully result in positive treatment outcomes. Therapists partner with clients to determine the most appropriate treatment path to follow. There is no specific content to CDOI—no particular ideas about why clients come to therapy or how they be helped. Download a free description of CDOI (The CDOI Fact Sheet) athttp://www.talkingcure.com/reference.asp?id=66 To learn more about CDOI we recommend that you read Heroic Client,(Duncan, Miller and Sparks, 2004) available athttp://www.talkingcure.com/bookstore.asp?id=226

Why measure outcome and the alliance?  

Two robust findings in research have been shown to be strong predictors of a positive treatment outcome: early change and the client’s subjective rating of the working relationship with the provider of services (known as the “alliance”).  Measuring outcome and alliance in real time provides opportunities to adjust treatment approaches to maximize the potential for a positive treatment outcome. Use of the ORS and the SRS has been shown to improve treatment outcomes by as much as 100%. In a recent study of feedback using the ORS and SRS, clients of therapists using the measures were four times more likely to attain clinically significant change than clients of therapist not using the ORS and SRS (Anker, Duncan, & Sparks, 2009).  Download free articles about CDOI research athttp://www.talkingcure.com/the_latest.asp?id=247  To learn more about CDOI we recommend that you read Heroic Client,(Duncan, Miller and Sparks, 2004) available athttp://www.talkingcure.com/bookstore.asp?id=226 or Heroic Clients, Heroic Agencies (Duncan & Sparks, 2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57

I know when my client is doing well so why do I need to add these measures to my sessions?

Therapists, as helpful as we are, seem to be notoriously bad at identifying clients at risk of dropping out or a negative outcome. Hannan et al. (2005) compared therapist predictions of client deterioration to actuarial methods. Though therapists were aware of the study's purpose, familiar with the dependent measure, and informed that the base rate was likely to be 8%, they accurately predicted deterioration in only one out of 550 cases; psychotherapists did not identify 39 out of the 40 clients who deteriorated. In contrast, the actuarial method correctly predicted 36 of the 40. The measures give therapists a reliable and valid point of comparison to transparently discuss how therapy is going with the client and prevent drop out and a negative outcome. By formalizing the feedback process, clinicians ensure that their clients have the opportunity to voice any concerns that the clinician may not have been aware of. Use of the ORS and the SRS has been shown to improve treatment outcomes by as much as 100%. In a recent study of feedback using the ORS and SRS, clients of therapists using the measures were four times more likely to attain clinically significant change than clients of therapist not using the ORS and SRS (Anker, Duncan, & Sparks, 2009).  Download free articles about CDOI research athttp://www.talkingcure.com/the_latest.asp?id=247   To learn more about CDOI we recommend that you read Heroic Client,(Duncan, Miller and Sparks, 2004) available athttp://www.talkingcure.com/bookstore.asp?id=226 or  Heroic Clients, Heroic Agencies (Duncan & Sparks, 2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57

Do accreditation bodies and accept these measures?

Yes, accreditation bodies such as CARF accept the ORS and SRS as legitimate outcome measures of the client’s experience of change. The ORS and SRS offer a unique outcome measurement system because they measure change and the fit of service from the client’s perspective as opposed to other measures that look at symptom amelioration. Download free articles about CDOI research athttp://www.talkingcure.com/the_latest.asp?id=247   To learn more about CDOI we recommend that you read Heroic Client,(Duncan, Miller and Sparks, 2004) available athttp://www.talkingcure.com/bookstore.asp?id=226 or  Heroic Clients, Heroic Agencies (Duncan & Sparks, 2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57

What is the difference between evidence based practice and practice based evidence?

Evidence Based Practice (EBP) refers to therapy models or techniques that have been proven, through clinical research trials, to be effective treatment approaches as compared to no treatment or sham treatments. Practice Based Evidence (PBE) involves monitoring the effectiveness of treatment for each individual client. It could be argued that PBE is the best EBP. We can only truly know if a particular EPB model or technique is effective with a particular client if we monitor client progress (PBE). See the free download article “Evidence Based Practice: Talking Points” athttp://www.talkingcure.com/reference.asp?id=66

What is the Dodo Bird Verdict? Is it a valid argument?

The dodo bird verdict (“All have won and all must have prizes.”), taken from the classic Lewis Carroll tale, Alice in Wonderland, was first invoked by Saul Rosenzweig way back in 1936 to illustrate the equivalence of outcome among approaches—see more about Saul, the founder of common factors athttp://www.talkingcure.com/reference.asp?id=156. The dodo verdict is the most replicated finding in the psychological literature—encompassing a broad array of research designs, problems, populations, and clinical settings. For example, a recent study in the UK (Stiles, Barkham, Twigg, Mellor-Clark, & Cooper, 2006) comparing cognitive behavioral therapy (CBT), psychodynamic therapy (PDT), and person centered therapy (PCT) as routinely practiced, once again, found no differences among the approaches. In over 40 years of research, via partisan studies and meta-analytic research, no one technique or model has been shown to be superior to any other model or technique despite claims to the contrary (Duncan, Miller, Wampold, & Hubble, 2010). The constant research emphasis on comparisons between treatment models is an exercise in futility – all bona fide treatments work for some people some of the time.

Are treatment gains obtained by implementing real time feedback from outcome measures such as the ORS and SRS maintained over time?

The answer is YES.  Treatment gains measured at the end of treatment are predictive of gains measured at follow ups. Not only are outcomes improved by up to 100%, but treatment effects are enduring over time. A recent study of couples in Norway demonstrated that the feedback condition maintained its advantage over the non feedback group and achieved a 50% less separation/divorce rate. Stay tuned to the research page for this study  http://www.talkingcure.com/the_latest.asp?id=247

What is the difference between specific factors and common factors and why are common factors important?

Specific factors are those ingredients that are unique to a particular technique or model. They are the ingredients that define and distinguish appoaches, highlighting their differences. The common factors have a long and rich history that started with Rosenzweig’s (1936) classic article “Implicit Common Factors in Diverse Forms of Psychotherapy.” In addition to the original invocation of the dodo bird and seminal explication of the common factors of change, Rosenzwieg also provided the best explanation for the common factors, still used today. Namely, given that all approaches achieve roughly similar results, there must be pantheoretical factors accounting for the observed changes beyond the presumed differences among schools—see more about Saul, the founder of common factors athttp://www.talkingcure.com/reference.asp?id=156 Meta-analytic research points to the existence of five factors common to all forms of therapy despite theoretical orientation (dynamic, cognitive, etc.), mode (individual, group, couples, family, etc.), dosage (frequency and number of sessions), or specialty (problem type, professional discipline, etc.).  One common factor dominates the lion's share of change, that is extratherapeutic or client factors, accounting for 87% of change. The remaining 13% of change can be attributed to treatment effects, wherein the other four common factors are found. In order of their relative contribution to change, these elements include: (1) Therapist Effects; (2) The Alliance; and (3) The general effects of delivering any treatment model (hope, expectancy, and allegiance) plus specific effects—the Model/Technique delivered; and 4) Feedback Effects. For more information download Barry’s Standard handouts at http://www.talkingcure.com/reference.asp?id=67

Or see The Heart and Soul of Change (Duncan, Miller, Wampold, & Hubble, 2010) soon to be available on the bookstore page. Barry first tried to operationalize the factors into clinical practice in the book Changing the Rules and the article “Applying Outcome Research” available for free athttp://www.talkingcure.com/reference.asp?id=156 and later refined in Escape from Babel with Scott and Mark (Miller, Duncan, & Hubble, 1997).http://www.talkingcure.com/bookstore.asp?id=53

What is meant by the “Client’s Theory of Change”

This concept was first developed by Barry in the book Changing the Rules (Duncan, Solovey, & Rusk, 1992). The client’s theory of change is his or her pre-existing beliefs about the problem and change.  Rather than reformulating client complaints into our own orientation, we do the opposite by elevating the client’s perception above our theories and allow the client’s view of change to direct therapeutic choices. (Heroic Client, p 72). Books available athttp://www.talkingcure.com/bookstore.asp?id=226 A free article about the Client’s Theory of Change can be downloaded athttp://www.talkingcure.com/reference.asp?id=156

The Outcome Rating Scale and the Session Rating Scales: Download free for personal use athttp://www.talkingcure.com/bookstore.asp?id=226

Why are there no numbers on the scales?

There are no numbers on the scales because people imbue meaning into numbers that can influence the accuracy of the measures. Both the ORS and the SRS are visual analog scales. Visual Analog Scales are designed to provide a rating scale with minimum constraints that allows clients to bypass thinking about what the numbers may mean and therefore provide a more accurate depiction of his or her subjective distress. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures at http://www.talkingcure.com/the_latest.asp?id=247

How and when do I administer the ORS and SRS to clients?

The ORS is administered at the beginning of sessions and the SRS is administered at the end of sessions. When administering the SRS it is important to leave adequate time to discuss any scores that indicate dissatisfaction with the session. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57

Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

How frequently should the measures be administered?

The ORS is designed to be administered at each session. In residential settings it is suggested that the ORS be administered at the beginning of each week.  The SRS on the other hand, can be administered at each therapeutic contact. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 Download free articles about the measures at http://www.talkingcure.com/the_latest.asp?id=247

Are the scales available for children and adolescents?

Yes, measures are available, and are reliable and valid, for children and adolescents. The Child Outcome Rating Scale (CORS) and Child Session Rating Scale (CSRS) are designed for use with children ages 6-12 although younger children may struggle with the year 8 reading level. Adolescents are administered the adult ORS which has a year 13 reading level.  The Young Child Outcome Rating Scale (YCORS) and the Young Child Session Rating Scale (YCSRS) are designed for use with younger children or those who are pre-literate, and are not intended to be scored. These measures are part of the download packet available free for individual use.  For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

How do I score the YCORS?

There is no numeric value attached to the visual representations of distress on the young child measures YCORS and YCSRS. These measures are designed to be used as clinical tools to assist in soliciting information from the child’s perspective on how things are going. Discussion with the child about the meaning behind the representation they choose gives focus to the work and allows opportunities to determine if change is occurring over time.

What are the psychometrics of the ORS and SRS?

ORS:

Validity: Correlates .59 with the OQ-45.2;.57 with the Symptom Checklist-90-R; .67 with the Clinical Outcomes in Routine Evaluation

Reliability: in the .8’s.

Feasibility: Takes less than a minute to administer and score and has compliance rates in the 90’s (v. 14%)

SRS:

Validity: Correlates .5 with the HAQ-II.

Reliability:of .83.

Feasibility: Takes less than a minute to administer and score and has compliance rates in the 90’s (v. 14%)

For more information, download the ORS/SRS Administration and Scoring Manual. Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

Do I need a license to use the ORS and SRS?

Yes, a license is required. As an individual practitioner you can download the measures from the website athttp://www.talkingcure.com/bookstore.asp?id=226 and use them for free. A license agreement is included. However, a group license must be purchased for agencies. If you subscribe to MyOutcomes.com to manage your data, a license agreement is included in the cost to the program.

Can I change the wording on the scales to fit my particular setting?

Alteration of the ORS and SRS is a violation of the licensing agreement.  Any changes contaminate the standardization of the measures and potentially harm their credibility. The relevant section of the license reads: 

3. License: Subject to the terms and conditions of this agreement, PCOMS grants to the licensee a license to use the measures in connection with the licensee’s bona fide health care practice.  The administration and scoring manual, and any and all electronic versions or scoring products associated with the measures may NOT be copied, transmitted, or distributed by the licensee.  Paper and pencil versions of the measures may be copied for use in connection with the licensee’s bona fide health care practice. 

4. Modifications:  The licensee may NOT modify, translate into other languages, change the context, wording, or organization of the measures  or create any derivative work based on them.  The licensee may put the measures into other written, non-electronic, non-computerized, non-automated formats provided that the content, wording, or organization are not modified or changed.  The licensee may modify the item line length so that each prints out 10 cm.

When I download the ORS and SRS from the website, the lines on the scales do not equal 10 cm. Why?

The scales print out at differing lengths depending on the computer. The measures are downloaded in Word format so that people can adjust the length and print the scales at exactly 10cm. 

How can you really talk to a client about progress (or lack thereof) from only the four broad categories on the ORS?  Wouldn't it be more helpful to have items that rate symptoms?

The ORS was designed as a brief alternative to the OQ45 developed by Michael Lambert and colleagues and as such, measures change in three areas of client functioning widely considered to be valid indicators of client progress in treatment: Individual (or symptomatic) functioning, interpersonal relationships and social role performance. As it turns out, about all outcome measures, whether symptom oriented or not, all measure the same thing—distress. Therefore, monitoring client distress in the major domains of life is a valid indicator of benefit from therapy. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

What does the Overall scale refer to?  How is it different from the Individual scale?

The overall scale is a synthesis of the other three scales on the ORS. It is a big picture look at one’s life rather than a specific look at how one doing individually. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

Administration, Interpretation and scoring of CDOI measures:

free for personal use athttp://www.talkingcure.com/bookstore.asp?id=226

How do I score the ORS and SRS?

The scales on each measure should be calibrated to 10cm. The client places a mark on the scale representing how they have been doing over the past week or since the last session. To score the measure, place a 10 cm ruler on the line to generate a corresponding number out of 10. Then simply add the numbers from each scale to get a total score out of 40. This score can then be plotted on a graph to track scores from session to session.  For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

Why do I have to get the scales filled in during the first session?

Having the scales completed during the first session is important for a number of reasons. Incorporating the measures at first session sets the tone for developing a culture of collaboration and inclusion of the client’s voice generated by eliciting client feedback in real time at each contact in the counseling process. Administering the ORS at first contact establishes a baseline to determine the treatment effect size, a way that you compare your performance to others. Most importantly, it provides an anchor of where the client is and allows a comparison point later on, as you progress through therapy. Clients often experience relief of distress after an initial session so the earlier we can capture the pre- treatment distress level, the more accurately we can determine the effectiveness of therapy. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

What is the “cutoff” on the ORS? What does it mean?

The cutoff on the ORS is 25. Most clients in therapy fall below the cutoff. Caution should be taken if the initial ORS score falls above the cutoff because clients have little room to realize positive change and research indicates that these clients tend to get worse with treatment. The assertion that clients tend to get worse with treatment when they enter with scores over 25 is a research finding based on 65,000 clients. Keep in mind that this is an aggregate finding at a 50th percentile trajectory. Clients can still improve, but the average client doesn't. So caution is warranted to ensure that clients don't get worse. One fourth to one third of clients, depending on the setting, will come in over the cutoff.

Note:  The clinical cutoff for children 6-12 completing the CORS is higher at 32 and for adolescents 13-17 it is 28. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

Why is the cutoff on the SRS so high? Does it mean there is a good alliance if the score falls above the cutoff?

First, all alliance measures are scored high so it is not surprising that the SRS is scored similarly. It is hard to give negative feedback. The cut off on the SRS is 36 because most people will scores above 36. For this reason, scores above cutoff are difficult to interpret.  Low ratings on the SRS are always a concern, especially when they don’t improve. Clients do have idiosyncratic responses to the measures, but the question is whether “a culture of feedback” has developed to the extent that clients will share the problem more specifically. The therapist should convey the attitude that he or she depends on the feedback to do good work, and that client feedback is critical to a positive outcome—clients must believe that they are central to the work, true partners in the process. There is never any bad news on the measures.

Here is a categorical way to think of SRS scores:  

• An SRS score that is poor and remains poor predicts a negative outcome (or dropout)
• An SRS score that is good and remains good predicts a positive outcome
• An SRS score that is poor or fair and improves predicts a positive outcome even more (This suggests that clients like therapists who respond to feedback and fits very nicely with the alliance rupture literature that says that clients like therapists who take negative feedback and do something about it—in fact, it almost doubles the possibility for a positive outcome.)
• An SRS score that is good and decreases is predictive of a negative outcome (or dropout)
• For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client athttp://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

What about client's complimenting you because they want you to think well of them?

It is important for the therapist to be clear in the explanation of the purpose of the measures and the importance of honest feedback. Always thank clients for the feedback and continue to invite their feedback. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

Why can't I just put the numbers on the scales?

Adding numbers to the scales not only violates the licensing agreement but also affects the validity and reliability of the measures because they were standardized without numbers. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

What do I do if clients put numbers instead of marks on the line?

Providing clear instructions to clients on how to complete the measures is important. If over time a client changes the way they fill in the form you may want to review the instructions with them. Clients will mark the scales in idiosyncratic ways. That’s okay. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

What do you do if the client scores high on the ORS, but their life is in such chaos (from your perspective) that it can't possibly be accurate?
An important aspect of using the measures to work with clients is to systematically discuss the scores with clients to ensure that marks on the lines actually reflect clients’ described experience of their lives. This entails eliciting the client’s perspective on what the marks mean, so that you are on the “same page” regarding what the marks say about the therapeutic work and whether the client is making any gains from his or her point of view. Otherwise, the measures can rapidly become an amorphous representation of who knows what. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

What is the meaning of 'effect size' and 'aggregated effect size," and why are these important to know?

Effect size (ES) is a form of standardized change score. It is calculated by dividing the actual raw score change by the standard deviation of the measure. You have probably seen it in descriptions of psychotherapy efficacy or effectiveness. It is often reported that the average treated person is better off than approximately 80% of the untreated sample, translating to an effect size (ES) of about 0.8.  Tracking your ES or your agency’s ES allows you to know how you are doing in comparison to other therapists and agencies so that you improve your effectiveness. You can calculate your ES fairly easily but it is important to note that the client’s intake scores greatly influences how much change can occur. MyOutcomes, a web based system for administering and storing ORS and SRS scores, automatically adjusts the ES based on the intake score so that fair comparison can be made. Aggregated ES provides a picture of the overall effectiveness of treatment provided by an individual, team, program or agency as a whole. For more information on effect size refer to The Great Psychotherapy Debate (Wampold, 2001)or the ORS/SRS Administration and Scoring Manual at http://www.talkingcure.com/bookstore.asp?id=226 Download free articles about the measures at http://www.talkingcure.com/the_latest.asp?id=247

What's the sense in grouping work/ study/ friendships together when things might be very different in each area?

The key here is to ask the client to mark the scale in reference to the topic or area for which he or she is seeking help. For example, if things are good socially and with friendships but there is some concern about work, ask the  client to score the measure based on how things are going at work rather than providing an “average” score. Just keep in mind that you want the ORS to reflect the problem you are working on in therapy and to reflect the gains made. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

Why are work and school grouped under the heading of "Socially"? 

The Outcome Rating Scale was developed to access 3 major categories of client functioning. Social functioning includes work and or school. Have the client mark the scale with the problem they are seeking therapy for in mind. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

How should clients make a distinction between close relationships as rated on “Interpersonally” scale and friendships, as rated on the “Socially” scale?

One way to distinguish these categories is to have the client provide an explanation as to what constitutes a close relationship versus a friendship from their perspective. Having clients provide their ideas about the distinction not only provides concrete information on what to focus on in treatment but also provides clarification on what change needs to happen in order for clients to realize change from session to session in a particular category. But generally, the “Interpersonal” scale refers to close relationships such partners and family, while “Social” refers to relationships outside the family. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

What is the minimum effect size that is considered clinically significant?

 “Clinical significance” and effect sizes (ES) are entirely different. Clinical significance generally means that the reliable change index (RCI) has been accomplished plus the clinical cutoff has been surpassed. This is also called “recovery.” On the ORS, this means that the ORS score has increased by 5 (the RCI) and went over the clinical cutoff of 25. Effect size (d) is a form of standardized change score. It is calculated by dividing the actual raw score change by the standard deviation. Effect size is adjusted based on the intake score because low scores offer more room for change. One way to interpret Effect size is  by following Cohen’s designation (Cohen 1988) which categorizes Effect size as follows: d= .2 (small ES); d= .5 (medium ES); d= .8 (large ES). For more information on effect size, see The Great Psychotherapy Debate (Wampold, 2001) or download the ORS/SRS Administration and Scoring Manual or The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 or download free articles about the measures at http://www.talkingcure.com/the_latest.asp?id=247

How do you decide when to end counseling from a CDOI perspective?

One of the overriding guiding principles of CDOI is honoring the clients’ perspective or voice in the therapeutic process. As such, any decision regarding the cessation of treatment would involve a collaborative decision between the helper and the client.

 Some things to consider are:

1. Have goals been met (from the client’s perspective)
2. If ORS scores plateau, sessions could be spaced out to ensure gains are maintained over time.
3. If the client is feeling stuck, consider changing the approach or the counselor pairing in hopes of finding an approach or pairing that will result in positive change. For more information, download the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

CDOI in specialized settings and populations

Can I use the ORS and SRS with families or couples?

Yes, in family and couples counseling, the measures are given to each family member present at the session. Discussing differences in scores can focus family work and generate rich conversations. Research conducted by Anker, Duncan, & Sparks (2009) using the ORS and SRS with couples yielded impressive outcomes. If a child is the reason for the therapy, the parents or caregivers rate the child, not themselves. For more information on using the measures with families and couples see the ORS/SRS Administration and Scoring Manual or purchase the book The Heroic Client at http://www.talkingcure.com/bookstore.asp?id=226 orHeroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57Download free articles about the measures athttp://www.talkingcure.com/the_latest.asp?id=247

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Can the measures be used with “severely mentally ill” clients?

Yes, in fact many agencies have been successfully using the measures with so called SPMI clients. See Heroic Clients, Heroic Agencies (2007 E version) athttp://www.talkingcure.com/bookstore.asp?id=57

How do you use the measures with mandated clients? Are their differences in ORS scores (i.e. above cut-off?)

The ORS and SRS can be used with mandated clients in the same manner they are used with any other client. There is a common misconception that mandated clients will lie about their scores. This is not born out in reality. Here are some results from a study by Miller, Duncan et al. about mandated/voluntary clients in a substance abuse program. These results are reported in an article “The Partners for Change Outcome Management System” athttp://www.talkingcure.com/reference.asp?id=66

•         ORS for people in tx for drug and alcohol abuse. Slightly more than half of the sample (53%) sought tx voluntarily.   

•         The average ORS intake score in the study was significantly higher (i.e., less distress) than the figure reported for a general mental health population (24.1 versus 19.6);

•         The general trajectory of change for the sample was also different.  General mental health clients tend to get worse with tx when their initial score fell above the clinical cut off of 25.  Clients in tx for drug and alcohol problems improved regardless of their intake score.

•         Second difference: Consistent with other studies on alcohol and drug tx, longer contact resulted in better outcomes. By contrast, a general mental health sample showed little or no gain after the first handful of visits.

 •         Third, clients who completed the program—whether voluntary or mandated—averaged significantly more change than those who dropped out (10.8 versus 7.4 points of change, p < .05). 

•         Sample divided into 4 groups: (1) voluntary clients who completed the program successfully; (2) voluntary clients who ended unsuccessfully; (3) mandated clients who completed the program successfully; and (4) mandated clients who ended unsuccessfully. 

•         Successful cases were defined as those who completed the six-month program, maintained employment, and had no positive urine screens.  Interestingly, mandated clients who ended unsuccessfully were the only group that initially scored above the clinical cut off.

•         This group was also the only one whose change scores were not significantly different from intake to last recorded session.  People who are mandated and score above the clinical cut off are indicating that they are not distressed. Therapists need to exercise greater skill in keeping such clients engaged.

Can the ORS/SRS be used with people who also have a diagnosis of a mild/moderate learning disability?

 The ORS and SRS are “user friendly” for people with all kinds of learning or cognitive styles. Usually, they just require simple initial guidance. There is no specific protocol that must be followed when administering the measures so you can’t over explain them. Do whatever it takes to help the client understand them. It is worth the investment because ensuring the client’s voice in his or her own care pays big dividends. Having a “learning disability” does not necessarily imply difficulty understanding or filling out the forms. The child scales are being used with children who have been diagnosed with learning disabilities. Although these scales were designed for use with children, they can be used with clients of any age, including adults who may experience difficulty with the adult versions (ORS and SRS).

Are there a group ORS and SRS measures?

The ORS can and is being used in group counseling as it is the measure of the individual’s level of distress. A group SRS has been developed that measures the client’s experience of the group facilitator as well as the group as a whole. The group SRS is currently undergoing validation studies and should be made available in the near future.

Are the scales available in other languages?

Yes, the measures are currently available in several other languages. Translations can be accessed athttp://www.talkingcure.com/bookstore.asp?id=226 

Can CDOI be used in inpatient settings?

Yes, CDOI can and is being used effectively in inpatient treatment settings. Frequency of administration of the measures in these settings is something that needs to be considered. It is recommended that the ORS be administered no more frequently than once a week.