Tipping an Organisation Upside down ….a work in progress….

Becoming a client directed and outcome informed organisation

Our Assumptions ….

• We all want the best outcomes for the people we work with / for

• We all want to use the resources we have to help as many people as possible

• We all value justice / fairness

Why Wesley Community Action opted for a Client Directed and Outcome

Informed (CDOI) approach

• Values

• The research evidence

• Global change driving local reality

What is Client Directed and Outcome Informed (CDOI) ?

• Describes interactions where;– The clients voice is privileged– The worker purposefully forms a relationship

based on the client’s Theory of Change– This work is informed by the client’s

experience of the alliance and the outcomes

Factors accounting for successful outcome- Michael Lambert

Spontaneous RemissionClient/Extratheraputic

Models/Techniques

Placebo/Hope/Expectancy

Common FactorsRelationship

The Therapeutic Alliance

Goals, Meaning or Purpose

Means or Methods

Clients view of the Therapeutic Relationship

The Research base?

• 9 Randomised Clinical Trials

• Over 1000 international studies and published articles

The largest study ever conducted on the treatment The largest study ever conducted on the treatment of problem drinkingof problem drinking

Three different treatment approaches Three different treatment approaches studied (CBT, 12-step, and Motivational studied (CBT, 12-step, and Motivational Interviewing).Interviewing).

Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58Journal of Studies on Alcohol, 58, 7-29., 7-29.Babor, T.F., & Del Boca, F.K. (eds.) (2003). Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK.Cambridge University Press: Cambridge, UK.Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. outcome. Journal of Consulting and Clinical Psychology, 65Journal of Consulting and Clinical Psychology, 65(4), 588-98.(4), 588-98.

The client’s rating of the therapeutic alliance the best The client’s rating of the therapeutic alliance the best predictor of:predictor of:

Treatment participation;Treatment participation;Drinking behavior during treatment;Drinking behavior during treatment;Drinking at 12-month follow-up.Drinking at 12-month follow-up.

Project MATCH Project MATCH The AllianceThe Alliance

Project MATCH Project MATCH The AllianceThe Alliance

•NO difference in outcome between approaches.NO difference in outcome between approaches.

Considered to be the most sophisticated Considered to be the most sophisticated comparative clinical trial ever conductedcomparative clinical trial ever conducted

Four approaches (CBT, IPT, Drug, Placebo)Four approaches (CBT, IPT, Drug, Placebo)

Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82.

No No differencedifference in outcome between in outcome between approaches. The approaches. The client’s client’s rating of the rating of the alliance at the second session, the best alliance at the second session, the best predictor of outcome across conditions.predictor of outcome across conditions.

TDCRP TDCRP The AllianceThe Alliance

TDCRP TDCRP The AllianceThe Alliance

How does it work

• 2 forms

• The first – Outcome Rating Scale – privileges the clients voice, promotes the clients Theory of Change and ensures transparency regarding agreed outcomes and monitoring of change

• The second- Session Rating Scale –measures the ‘fit’ between worker and client

The Outcome Rating Scale (ORS)Measuring Outcome

Looking back over the last week, including today, help us understand how you have been feelingby rating how well you have been doing in the following areas of your life,

where marks to the left represent low levels and marks to the right indicate high levels.

Individually:(Personal well-being)

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Interpersonally:(Family, close relationships)

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Socially:(Work, school, friendships)

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Overall:(General sense of well-being)

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The Session Rating Scale (SRS)Measuring the Alliance

Please rate today’s session by placing a hash mark on the line nearest to the description thatbest fits your experience.

I did not feel heard,understood and

respected  

We did not work on ortalk about what I

wanted to work on andtalk about

  

The therapist’sapproach is not a good

fit for me  

There was somethingmissing in the session

today

I felt heard,understood and

respected  

We worked on andtalked about what I

wanted to work on andtalk about

  

The therapist’sapproach is a good fit

for me  

Overall, today’s session was right for

me

Relationship: 

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 Goals and Topics:

 |------------------------------------------------|

 

Approach or Method: 

|------------------------------------------------|

  Overall:

 |------------------------------------------------|

What are the implications for WCA in adopting a Client Directed Outcome Informed Approach ?

A Riddle - What is the difference between:

– baking a cake;

– sending a rocket to the moon;

– raising a child?

Develop common ground,

compromise

or compete.

Use experts to experiment and find the answers

Learn by doing with clients and keypeople.

Create stability.

Follow the ‘best practice’

recipe.

Client led Complex Issues

Feature

• Difficult to frame• Multiple root causes• Multiple stakeholders• Emergent• Unique• Paradoxes, Dilemmas

Response

• Good enough framing• Cross boundary work• Collaborative & Flat• Adaptive Learning• Customized Responses• Transparent coping

“Living systems can only be disturbed never directed” Maturana and Varela

And all organisations are living systems (changing, sometimes messy, holding many truths)

Preconditions for Client Directed Approach - Wesley Community Action’s

Journey

• St Lukes training – 2002• Intentional strength based practice – 2003• Leadership – confirming SB approach• SB conference 2007 Palmerston North – presentation

Dr Barry Duncan • Visits by Barry in 2008,2009 and 2010• Leadership – confirming CDOI• Data Management System• Wesley Way 2011 – organisation practice framework.

The Wesley Way

How WCA implemented it ..

• Developing the frameworks that support this – an expectation of a culture of feedback

• Training and Supervision – Internal and external

• Water Cooler conversations – staff feeling OK with discomfort in using the tool

• Accepting Data as our friend – collecting and collating it

Client Voice

Is it really tipping the organisation upside?

YES We moving from an organisation where ...

• Staff believe they actually change people. • The organisation takes the credit for the hard work of

the clients• We blame the clients it they are not changing how we

expect them to• We design our systems as if clients are invisible or

passive• We ‘train’ clients how to be receivers of help

•• .

To an Organisation where we..

• understand that people only change when they intrinsically want to change and ...

• create an environment conducive for people to do the right thing for them.

• Are great at spotting and celebrating positive changes made by clients

• Value regular honest feedback from clients