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Edition 5 – August 2014
Gateway to FamilySmart™Evidence
Therapy directed by client feedback is more effective and has better outcomes than typical treatment.18
The percentage of clients who prematurely drop out of services in traditional mental health settings was nearly 50%.3,7
Individuals who receive treatment from a consumer-‐driven/family-‐driven approach show improvements with reduced symptoms and enhanced self-‐efficacy, social integration and empowerment.9
Feedback informed approaches, FIT and OQ, are certified by SAMHSA’s National Registry for Evidence-‐Based Programs and Practices.22
To create change in mental health care systems requires consumer and family participation in all facets of mental health, from service planning, delivery and evaluation. 5,8
QUICK FACTS
Creating a Culture of Feedback: Feedback Informed Child and Youth
Mental Health Care The concept of recovery is central to the Mental Health Commission of Canada’s recommendations to transform mental health care.1,2 Recovery is “a process or journey of healing in which, to the greatest extent possible, people are empowered to make informed choices about services, treatments and supports that best meet their needs”.1 The principles of recovery include: hope, empowerment, dignity, self-‐determination, respect and responsibility.1,3 Within a recovery-‐orientated system is the notion of partnership with services providers and shifting services from a professional-‐driven to a consumer and family-‐driven model.1,2 This is a model whereby:
[…] consumers choose their own programs and the providers that will help them most. Their needs and preferences drive the policy and financing decisions that affect them. Care is consumer-‐centred, with providers working in full partnership
with the consumers they serve to develop individualized plans of care.21
Silenced Voices
Traditional mental health services have fostered an environment of dependency and helplessness for its consumers.4 For families, this entailed a silencing of their voices—parents were viewed as a source of the problem and were “blamed and shamed”.5 These traditional service models focused on deficits, limited family involvement, restricted client choice and responsibility, and viewed families as passive recipients of services.6 The repercussions of this model can be seen in the number who discontinue services.3 In a meta-‐analysis of 125 studies, it was determined that nearly 50% of clients’ dropout out of services prematurely.3,7 This statistic highlights the need for services that work for clients and not the other way around.3
Despite mental health reform agendas focusing on empowering consumer and family voice, it is rare for mental health systems to gather experiences of service and even rarer to use this information to improve service quality.8 Part of the reason for not including family-‐driven strategies may be due to attitudes, procedures or policies, and lack of training opportunities for families or professionals6. To create change in mental health service requires consumer and family participation in all facets of mental health services, from service planning, delivery and evaluation.5,8 It is creating a culture that is open to family involvement and feedback that is part of the system itself.3
Creating a Culture of Feedback in Child and Youth Mental Health
The value of consumer-‐driven and family-‐driven models is clear.5 In a randomized controlled trial (RCT) -‐ the “gold standard” for research -‐ participants who received treatment from a consumer-‐driven approach, in contrast to those who received standard care, showed greater improvements with reduced symptoms and enhanced self-‐efficacy, social integration and personal empowerment.9 For individuals receiving mental health services, choice, self-‐direction and empowerment are considered crucial helping factors.23 Furthermore, the involvement of families and their children as active participants in the services they receive is linked with improved outcomes.5,11,12,13 To create this culture of authentic consumer and family-‐driven models requires not only a refinement of policy that enables involvement,5,8 but also a shift in practice and how services are delivered. A model that demonstrates principles of consumer-‐driven/family-‐driven, recovery-‐orientated services is Feedback-‐Informed Treatment (FIT).3,14,15
Feedback Informed Mental Health Care
FIT, also known as Client-‐Directed Outcome-‐Informed therapy (CDOI), is an approach to mental
Edition 5 – August 2014
Gateway to FamilySmart™Evidence
Fred Chou, M.A., C.C.C., is a Ph.D. student in Counselling Psychology at the University of British Columbia Keli Anderson, is the President & CEO of the National Institute of Families for Child & Youth Mental Health and co-‐founder of The F.O.R.C.E. Society for Kids' Mental Health Dr. Marvin McDonald, Ph.D., R.Psych., is the program director for the Master of Arts in Counselling Psychology at Trinity Western University
AUTHORS THOFACTS
health treatment that is guided by clients and their feedback .14,15 This feedback involves the process of treatment, the relationship with the therapist/professional, and the overall wellbeing of the client.15 Involving feedback while monitoring outcomes increases service effectiveness and outcomes, and reduces premature discontinuation of services.17,18,19 In an analysis of 5 major RCT studies which involved more than 4000 participants, therapy that was informed and directed by client feedback was more effective and had better outcomes than typical treatment that was not guided by feedback.18
FIT was derived out of the Outcome Questionnaire (OQ) and provides two areas of assessments: (a) Outcome Rating Scale, which assesses the progress and the client’s perceived benefit of treatment, and (b) the Session Rating Scale, which measures the quality of the relationship with the therapist/professional.15,18 These scales have been adapted and utilized with children, youth and their families.16 The formation of FIT and OQ is connected with: principles of recovery; the value of client voice and feedback; and research on common factors that help clients change.3,15
Both FIT and OQ move away from professional-‐directed treatment towards consumer-‐directed, individually tailored treatment that directly involves clients in collaboratively making decisions about their treatment.3 The value of actively involving clients in therapy is emphasized in the common factors research; the two most important elements of change are the clients themselves and their relationship with their helper.20 Both FIT and OQ are certified by SAMHSA’s National Registry for Evidence-‐Based Programs and Practices (US Department of Health), therefore meeting a standard of excellence that proves its effectiveness as a treatment approach.22
Implications
As there is incredible value in the feedback that clients provide, professionals should consider making formal strategies to collect client feedback in practice18,21—whether that is utilizing FIT, OQ, or simply asking what helped and hindered during therapy sessions.21 FIT is one strategy that tangibly involves client voice in creating a culture of feedback. The inclusion of client
voice in shaping services results in better outcomes.3,18 Though FIT represents one area of eliciting feedback in mental health care, it is evident that there is value in consumer and family-‐driven models and their input. The intentional and systematic involvement of client voice through feedback in mental health systems, including other areas such as program development and policy, can lead to a successful transformation in child and youth mental health care.3
References
1. Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health strategy for Canada. Calgary, AB: Author.
2. Canada, Parliament, Senate. (2006). Standing Senate Committee on Social Affairs, Science and Technology. M.J.L. Kirby (Chair) & W.J. Keon (Deputy Chair). Out of the shadows at last: Transforming mental health, mental illness and addiction services in Canada. 38th Parl., 1st sess. Retrieved from http://www.parl.gc.ca/content/sen/committee/391/soci/rep/pdf/rep02may06part1-‐e.pdf.
3. Bohanske, R. T., & Franczak, M. (2010). Transforming public behavioral health care: A case example of consumer-‐directed services, recovery, and the common factors. In B. L. Duncan, S. D. Miller, B. E. Wampold, M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed.) (pp. 299-‐322). American Psychological Association. doi:10.1037/12075-‐010
4. Brown, L. D. (2012). Consumer-‐run mental health: Framework for recovery. New York: Springer
Did you know? The Southwest Behavioral Health Services a large, non-‐profit, multidisciplinary community mental health organization in Phoenix, Arizona that fully implements FIT clinical services. When reviewing data from the first 18 months of implementing FIT, involving over 1500 clients, there was a dramatic increase in client reported successful completion of treatment and a reduction in clinician caseload in comparison to traditional mental health services.3
Edition 5 – August 2014
Gateway to FamilySmart™Evidence
5. Spencer, S. A., Blau, G. M., & Mallery, C. J. (2010). Family-‐driven care in America: More than a good idea. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 19(3), 176.
6. Chovil, N. (2009). Engaging families in child & youth mental Health: A review of best, emerging, and promising practices. The F.O.R.C.E. Society for Kids’ Mental Health.
7. Wierzbicki, M., & Pekarik, G. (1993). A meta-‐analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24(2), 190-‐195. doi:10.1037/0735-‐7028.24.2.190
8. Ning, L. (2010). Building a 'user driven' mental health system. Advances in Mental Health, 9(2), 112-‐115. doi:10.5172/jamh.9.2.112
9. Segal, S. P., Silverman, C. J., & Temkin, T. L. (2010). Self-‐help and community mental health agency outcomes: a recovery-‐ focused randomized controlled trial. Psychiatric Services, 61 (9), 905–910. doi: 10.1176/appi.ps.61.9.905
10. Onken, S. J., Dumont, J., Ridway, P. Dornan, D., & Ralph, R. (2002). Mental health recovery: What helps and what hinders? Alexandria, VA: National Technical Assistance Center for State Mental Health Planning, National Association of State Mental Health Program Directors.
11. Morrissey-‐Kane, E., & Prinz, R. (1999): Engagement in child and adolescent treatment: The role of parental cognitions. Clinical Child and Family Review, 2, 183–198.
12. Wehmeyer, M., & Palmer, S. (2003): Adult outcomes for students with cognitive disabilities three years after high school: The impact of self-‐determination. Education and Training in Developmental Disabilities, 38(2), 131–144
13. Osher, T. W., Osher, D., & Blau, G. (2008). Families matter. In T. Gullotta &G. Blau (Eds.), Family influences on childhood behavior and development evidence-‐based prevention and treatment approaches (pp 39–61). New York: Routledge.
14. Duncan, B. L., Sparks, J. A., & Miller, S. D. (2006). Client, not theory, directed: Integrating approaches one client at a time. In G. Stricker, J. Gold (Eds.), A casebook of psychotherapy integration (pp. 225-‐240). American Psychological Association. doi:10.1037/11436-‐017
15. Duncan, B. L. (2012). The partners for change outcome management system (PCOMS): The heart and soul of change project. Canadian Psychology/Psychologie Canadienne, 53(2), 93-‐104. doi:10.1037/a0027762
16. Duncan, B., Sparks, J. A., Miller, S. D., Bohanske, R. T., & Claud, D. A. (2006). Giving youth a voice: A preliminary study of the reliability and validity of a brief outcome measure for children, adolescents, and caretakers. Journal of brief therapy, 5(2), 71-‐87.
17. Lambert, M. J. (2010). “Yes, it is time for clinicians to monitor treatment outcome.” In B. L. Duncan, S. C., Miller, B. E. Wampold, & M. A. Hubble (Eds.), Heart and soul of change: Delivering what works in therapy (2nd ed., pp. 239–266). Washington, DC: American Psychological Association.
18. Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48(1), 72-‐79. doi:10.1037/a0022238
19. Reese, R., Norsworthy, L., & Rowlands, S. (2009). Does a continuous feedback model improve psychotherapy outcomes? Psychotherapy: Theory, Research, Practice, Training, 46, 418-‐431.
20. Asay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 23-‐55). American Psychological Association. doi:10.1037/11132-‐001
21. McLean, S. (2012). Youth perceptions of child and youth mental health service discontinuation. Unpublished master’s thesis, Trinity Western University, Langley, Canada.
22. US Department of Health and Human Services. (2014). Substance Abuse and Mental Health Services Administration: National Registry of Evidence-‐based Programs and Practices. Retrieved from http://www.nrepp.samhsa.gov/Index.aspx
23. Onken, S. J., Craig, C. M., Ridgway, P., Ralph, R. O., & Cook, J. A. (2007). An analysis of the definitions and elements of recovery: a review of the literature. Psychiatric rehabilitation journal, 31(1), 9.
24. President's New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report (DHHS Pub.No. SMA-‐03-‐3832). Retrieved from http://govinfo.library.unt.edu/mentalhealthcommission/reports/FinalReport/downloads/FinalReport.pdf
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