Dans cet article inédit de 1998, le Professeur Wendel RAY présente une méthode d'évaluation de l’efficacité en terme de résultats du Brief Therapy Model utilisé dans le General Counseling Program du YWCA (Monroe – USA). Premièrement le Professeur Ray montre la nécessité d’une évaluation des résultats. Deuxièmement il présente le programme d’évaluation. Ensuite il explique comment implémenter ce programme dans la pratique des psychothérapeutes. Enfin il indique de façon générale les bases théoriques du Brief Therapy Model, c'est à dire la théorie interractionnelle des comportements humains. Wendel Ray termine l’article en montrant que l’utilisation du Brief Therapy Model permet de soigner un nombre majeur de patients par rapport à d’autres approches thérapeutiques.
YWCA General Counseling Program
Outcome Study - A Proposal
I. What to Examine and Why
If therapy is to be taken seriously as treatment its effectiveness must be reliably evaluated. But evaluating the effects of therapy is not an easy task. Anecdotal impressions of the effectiveness of therapy with no follow-up after termination of services is no longer sufficient to justify the confidence of consumers, managed care entities, and other potential funding sources.
In general, three different instruments are utilized to document the results of service provision:
1. Utilization review.
Utilization review tracks the average length of treatment by diagnosis. The tracking of this information is important, especially if you are treating a population with high levels of chronicity, like some of those seen at the YWCA. Gathering these numbers and breaking them down by diagnosis is important in demonstrating effectiveness of our treatment and are scrutinized by many third party reimburses and/or benefactors. For example, a lower number of sessions for the diagnosis of adjustment disorders as in contrast to more severe diagnosis is expected by most insurance providers. The YWCA has in place a satisfactory method for tracking this data.
2. Satisfaction survey.
Most managed care entities are very interested in the degree of satisfaction of clients in the services provided. Currently the YWCA have clients complete two different instruments which address this aspect of documentation: the general satisfaction instrument used to track client satisfaction with such elements as office surroundings, facility accessibility, et cetera; and the Satisfaction Scale adopted from Insoo Berg used to track client perception of progress. Both of instruments currently being used adequately track important information and should be retained with no revision.
3. Outcome studies.
Outcome studies are concerned with how therapy is done and the effectiveness of the therapy. The general approach to therapy being used by counselors at the YWCA is based on the brief therapy model developed at the Mental Research Center in Palo Alto, California. Concern with systematic evaluation of results has been a fundamental aspect of the brief therapy treatment approach pioneered at the MRI since the founding of the model in 1967. While the method of evaluation developed at the Brief Therapy Center relies somewhat on clinical judgment, and the method may appear overly simple in comparison with more traditional evaluation designs, the strength of this methodology is that it "is simple, avoids dependence upon either elaborate manipulation and interpretation of masses of detailed data or elaborate theoretical inference; it is reasonably systematic and practical; and most importantly, it is consistent with the treatment models overall approach to problems and treatment" (Weakland, et al, 1974). Since the use of an evaluation protocol by other researchers is an important evidence of the an evaluation procedures credibility, it is worthy of noting that the BTC Outcome methodology has been replicated by de Shazer, Berg, et al (1986) in their seminal outcome study of their solution focused brief therapy approach. The use of the MRI Outcome protocol by de Shazer is important because replication by other researchers using a related model of treatment and publication of the results in a leading professional journal strengthens the credibility to both the treatment methodology and outcome protocol.
II. The BTC Outcome Evaluation Methodology
From the MRI Brief Therapy perspective, the essential task of evaluation is systematic comparison of what treatment proposes to do and its observable results. The purpose of treatment is to change clients' behavior in order to resolve the main presenting complaint. A principal systemic assumption is that once change has been made in the main presenting complaint, this change will have a positive ripple effect throughout the client’s interactional contexts.
It is always difficult to determine if the changes made by a client can be attributed to the therapeutic intervention. However, given the brevity of the model (a standard maximum format of ten sessions), the consistent demonstration in the past of the models ability to work successfully with a widely diverse range of presenting complaint, both in terms of the nature and duration of the complaint, crediting observed changes to the treatment orientation is not unreasonable.
Evaluation depends on answers to the following questions:
- Has behavior changed as planned?
- Has the complaint been relieved?
In order to ascertain the answers to these questions, the following procedure for conducting a routine follow-up telephone contact with clients could be as follows:
- An interviewer, who was not the therapist and who has not participated in the treatment, reviews the case file for each client participant. The purpose of the review is to ascertain the contact person and telephone numbers for each client, and to familiarize the interviewer with the goal of therapy documented in the case file. Proposed change in information obtained at intake interview. A change should be implemented in the existing procedure used at the YWCA for obtaining follow-up telephone numbers/addresses of clients. At this time often only one or two telephone numbers are obtained from clients, usually either the home or work number. During the initial intake interview, the prospective client should be informed that a routine aspect of treatment here at the YWCA involves our making contact with them twice after treatment has been completed. This follow-up contact is done to assure the client has received appropriate and satisfactory assistance from the YWCA. It would then be explained to the client that in order to facilitate this follow-up care, since we live in such a mobile society, it would be helpful if they would provide several contact telephone numbers of people who will be able to get in contact with them in case they have moved (a family member, neighbor, etc.) in addition to their home and work numbers. An important aspect will be to assure the client that their confidentiality will be protected, and no information about their treatment will be conveyed to the contact person.
- At the three month point after termination of counseling, and again at the six month point, a follow up interviewer contacts the client by telephone and asks five questions:
1. Was the specified treatment goal met? For example: “Are you still living with your mother, or are you living in your own quarters now?
2. Next, the client is asked “What is the current status of the main complaint?” For example: “The main thing that brought you to therapy was depression over your break up with your fiancée. How are you doing now?
3. The third question inquires whether any further therapy has been sought since terminating counseling with the YWCA?
4. Have any improvements occurred in any areas not specifically dealt with in treatment?
5. Inquire if any new problems related to the original complaint have appeared since therapy was completed.
The purpose of this final question is to check on the supposed danger of symptom substitution.
III. Implementation
Implementation of a standardized outcome protocol within the General Counseling Program can be done with relative ease by:
- Implementing a few minor changes in the information obtained from clients during the initial interview (see 2 A. above).
- Familiarizing counselors with these changes and having them implement the new protocol.
- Initiating routine follow-up telephone interviews with clients at three month and six month intervals after termination of services.
Steps for Implementing the Procedure
Step I. The outcome proceedure will be explained to all clinicians.
Step II. Outcome procedure implemented with all clients seen in the General Counseling Program beginning January 1, 1998.
Step III. At the three month point after termination all clients contacted by telephone for follow-up inquiry.
Step IV. At six month point after termination of counseling with each client, the client is contacted by telephone for follow-up inquiry.
Step V. January 1999, data from all clients seen during 1998 is compiled into a formal report of outcome
IV. Exceptions and an Alternative Approach to Outcome Study
The YWCA of Monroe adheres to a policy of providing services to any and all individuals and families who seek counseling services. While the vast majority of complaints presented by clients can be successfully addressed using the brief therapy orientation, the nature of a small percentage of presenting complaints do not lend themselves to completion within the standard maximum ten session format used in brief therapy. These unique cases can be placed in two general categories:
- Cases which involve clients who require intensive involvement in multiple community services for an extended period of time (for example low income clients with special needs children). Such cases are often require involvement with clinical services for an extended period of time.
- Clients with presenting complaints which, based on apparent indicators should be treatable within the standard maximum ten session format used in brief therapy, but for one reason or another have continued in treatment for an extended number of sessions.
In order to identify these unique cases it is recommended that a consultation procedure be implemented as a routine aspect of all cases seen within the general counseling program. As a routine procedure, at the completion of the fifth interview, clinicians would review their progress to determine if they believe therapy is on track and can be completed within the 10 session framework. If there is any concern about being able to complete treatment in a timely manner, during supervision the clinician would request a team consultation on the case. On a case by case basis a refinement of treatment strategy would be implemented which would range in intensity from a case review of the case in group or individual supervision at one end of the continuum, to the scheduling of an interview using the one-way screen and use of a therapy team in the next and subsequent interviews.
Cases which fall in the first category (clients who require intensive involvement in multiple community services for an extended period of time and involvement with clinical services for an extended period of time) should not be retained within the outcome study protocol. The reason is that they will distort the outcome data.
V. Overview of the Primary Clinical Model used at the YWCA
An important aspect of outcome research pertains to the training and orientation toward treatment held by therapists who are participating in the study. It was pointed out at one outcome research workshop at the 1997 FSA conference that it is important for clinicians to have some consistency across clinicians in terms of treatment philosophy, technique, and supervision (Mueller & Owen, 1997). Such consistency is a fundamental prerequisite to meaningful outcome research. One definite strength of the YWCA general counseling program is that during the last seven years the YWCA has adopted and consistently maintained a systemic/interactional philosophical orientation among clinicians hired. Consistent with this philosophy, during the last three years specific focus of supervision has been orienting staff clinicians to the use of interactionally oriented brief therapy models, especially the MRI Brief, and two other models which are derived from the MRI approach, the Solution Focused, and Milan Systemic treatment orientations. This places the program in a position of being reasonably prepared to initiate outcome research as a routine aspect of treatment.
The Brief Therapy Model developed at the Mental Research Institute is based upon forty-five years of research investigations conducted by some of the most influential researchers in the field of marriage and family therapy and brief therapy. The sustained efforts of this group of investigators has led to more than fifty completed research projects, over forty books with many foreign language editions, over five hundred other publications, numerous international conferences, and the creation of an archive containing seminal materials from these endeavors (see Bateson, 1951, 1972, 1979, Bateson, Jackson, Haley & Weakland, 1956; Berber, 1978; Haley, 1963; 1981; Jackson, 1960, 1968 a & b, Watzlawick, Bavelas, & Jackson, 1967; Watzlawick & Weakland, 1977; Fisch, Weakland & Segal, 1982; Sluzki & Ransom, 1978; Weakland & Ray, 1995). Virtually every model of marriage and family therapy and brief therapy being used today has been influenced by the body of research conducted by researchers at the M.R.I. (Becvar & Becvar, 1995).
The ground breaking investigations of these researchers led to the development The Interactional Theory of human behavior. In essence interactional theory maintains that the most efficient way to understand behavior is by focusing on observable behavioral interaction occurring between people in the present. By attending to the present context in which problems occur, and the nature of the relationship between the people involved in the situation, rather than spending time and energy trying to figure out how things got to be the way they are, interactional theory seriously examines patterns of interaction happening between people involved in the situation currently that inadvertently perpetuate the problem behavior.
In attempting to understand the problems people experience that bring them to seek psychotherapy, interactional theory shifts the focus of attention away from looking at historical antecedents, and/or what may be going on inside of people, and instead focuses primary attention on what is happening in the present moment in the interaction between people as a more efficient way to understand and quickly resolve problems.
Once primary focus is shifted to observable exchanges of behavior between people, a profound and fundamental shift in understanding takes place about how problems are maintained in the interaction between people in relationships. The shift from the traditional search for why people have problems, which often leads to time consuming, costly, and fruitless speculation, to how problems are maintained allowed for the development of less time consuming and much more cost effective problem resolution. This revolutionary insight paved the way for the creation of one of the most practical and efficient models of therapy is use presently: the Brief Therapy Model of the MRI.
Fundamental Assumptions and Principals of the MRI Brief Therapy Model
One of the most salient and timely outcomes of these decades of research is the MRI Model of Brief Therapy, the first, most extensively researched, and most influential model of brief therapy in use today (see Fisch, Weakland, & Segal, 1982). From a wide variety of health care settings across the United States to psychiatric out patient care settings in Sweden (Pothoff, 1995), Israel (Soroka, 1995), Canada (Bavelas, 1995); Argentina (Elzufan & Hirsch, 1995), Ireland (Haughton, 1995), Japan (Mayata, In press), Italy (Nardone, 1995), and India (Appasamy, 1995) the MRI Brief Therapy Model is in use across the globe in diverse cultures and practice settings. The model is ideally suited for application in the current atmosphere of ever increasing concern over cost effectiveness and movement toward managed health care (Chubb, 1995).
The essence of efficient and effective therapy is to assist clients to define problems in ways that can be solved rapidly. Toward this end the principals and techniques of treatment of MRI brief therapy relate closely to the following two assumptions.
a. It is doubtful the origins of a problem can ever actually be determined, and attempting to do so locks therapy into a past-history framework. Therefore, regardless of how problems got started, the kind of problems that bring people to psychotherapists persist only if they are maintained by ongoing current behavior of the patient and others with whom he interacts. The MRI Brief Therapy approach emphasizes the focus on how problems are maintained, then designs a plan for interrupting problem maintaining behavior.
b. If such problem-maintaining behavior is appropriately changed or eliminated, the problem will be resolved, regardless of its nature, origin, or duration (Weakland, Fisch, Watzlawick & Bodin, 1974).
Approaching problem resolution on the basis of these two principles leads to the formulation and application of a four-step procedure in therapy:
1. Develop a clear definition of the problem in concrete terms.
2. Investigate the solutions the client has attempted thus far.
3. Develop clear, concrete, and attainable goals for change to
be achieved.
4. Formulate and implement a plan to produce this change
(Watzlawick, Weakland, & Fisch, 1974; Fisch, Weakland, &
Segal, 1982).
This brief therapy model embraces diversity in that it is a non-normative model, and is not attached to standards of “mental health”, “normal” family functioning, or the like. No effort is made to instruct clients on how they should choose to live. It is assumed the client is doing the best he or she can given the living situation they are adapting to. Emphasis is placed on the resourcefulness of the client (I.E. strengths and abilities) and his/her ability to depart from problem maintaining behaviors. This in no way accepts aberrant behavior such as violence or abuse, but instead investigates the context and interactional patterns maintaining the problem, then focuses on changing them.
As a complaint based model, the standard for entry into “treatment” is that someone is registering a complaint about themselves or another. The standard for terminating “treatment” is that the complainant no longer has a complaint. Resolution of the problem can be relatively brief since it, like all other problems, is actively maintained by the unwitting, albeit problem maintaining, efforts of the parties involved. Interdicting those efforts can and does result in the self extinction of the problem.
VI. Overview of Relevant Outcome Research:
The MRI Brief Therapy Model has been in use for more than thirty years, and Solution-Focused model for more than fifteen years. Thousands of mental health professionals have been trained in these two related models. The MRI model is being used across the world in diverse cultures and in settings ranging from in-patient, day treatment, private agencies, and major health management organizations. Outcome studies on brief therapy approaches based upon the MRI Brief therapy model have been completed at a number of different times and places during the past twenty-five years, while outcome research on the Solution-Focused model has been building for more than eleven years. These models have demonstrated effectiveness in working with a widest possible range of emotional and behavioral problems such as alcoholism (Fisch, 1986; Jackson, 1967; Berg & Miller, 1993), psychotic behavior (Haley, 1980; Jackson & Watzlawick, 1963; Jackson & Weakland, 1971; Fisch, Weakland, & Segal, 1982; Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1978), chronic depression (Coyne, 1967, In Press), domestic violence, severe marital discord, and parent-child conflict (Lane & Russell, 1989; Madanes, 1990; Sorka, 1995; Fraser, In Press, 1995; Ray, 1992), child/adolescent behavioral and school related problems (Hopwood, 1993, Amaeta, 1989), and sexual trauma (Dolan, Y., 1992; Everstine, D., & Everstine, L., 1989).
Measurement may not be the heart of science, but statistically significant results are definitely what counts in the world of psychiatric research today (Priebe, 1995). Chubb (1995) contrasted statistics for the years 1985-1986 of Kaiser-Permanente’s Pleasanton, California, psychiatric clinic, which adhered to the MRI Brief Therapy model, with other Kaiser-Permanente clinics that used psychodynamic-eclectic models. At the clinic using the MRI Brief Therapy Model 1,963 patients were seen. 48.0% of the total required only one session, 0.7% of the total were seen exactly nine times. 89.9% of Pleasanton patients were seen for five or less sessions and 97.5% were seen for ten or less. By contrast, the equivalent figures for another and more typical clinic which followed a more traditional pschodynamic / eclectic orientation, 69.5% were seen for five or less sessions and 89.3% were seen for ten sessions or less, respectively.
While these differences are striking, they fall to highlight the impact of longer-term therapy on clinic operation. A therapist can serve five four-session clients in the time it takes to see one twenty-session client. At the comparison clinic, 29.7% of all therapist hours were spent on cases that had already run at least ten sessions. The equivalent figure for Pleasanton was 4.0%. Had the comparison clinic (which, it must be emphasized, was typical and not an extreme case) been able to achieve the Pleasanton pattern for its longer cases, it would have been able to free up 25% of its therapist time for waiting list cases and ultimately to handle the same case load with a quarter less staff. Pleasanton averaged 2.5 sessions per patient and 834 different cases per therapist over the two year period. The equivalent figures for the clinic with the next most patients per therapist were 3.7 and 742. Regional means were 5.4 and 456; and of course about half the other clinics did worse than this.
Therapist productivity in a setting with limited resources is best measured not by contact hours per week but by total number of clients served. Therapist efficiency is in the interest of both the clinic and the clients. The Pleasanton clinic’s efficiency was not achieved at the cost of quality. Client satisfaction was high, as revealed by several user surveys. Another indicator of service quality is flow between nominal catchment areas. Kaiser subscribers are encouraged but not required to go to the clinic nearest them. A flow away from a clinic could suggest problems, but as far as could be determined net flow as substantially inbound. Finally, hospitalization rate may be a good indicator. If clinic clients rarely require hospitalization, outpatient care was the lowest in the region and only two-thirds of the regional average (Chubb, 1995).
A question has been raised among some mental health professionals regarding the efficacy of a brief therapy orientation when working with seriously mentally ill clients. Using the MRI brief therapy model, Nardone (1995) conducted a research study with a group of 41 clients diagnosed with serious phobic disorders such as agoraphobia, panic attacks, serious anxiety attacks or recurring immobilizing fear situations.
The group of clients treated was made up of 24 women and 17 men of different educational levels (elementary school, high school, college or university); ages range from 18 to 71. The sample included housewives, medical doctors, professionals and different kinds of employees. Therapy was completely successful with all 41 patients (I.E. symptoms and disorders presented when the patient came for therapy gradually disappeared and at the last session, were completely extinguished. A follow-up study conducted one year after completion of therapy revealed 32 of the clients had been completely and successfully treated, seven improved their problematic condition significantly, and the last two patients improved, but not fully recovered from their condition.
Percentage of Cases Length of Therapy
19.2% from 1 to 10 sessions
61.5% from 10 to 20 sessions
3.0% from 20 to 30 sessions
15.3% from 30 to 34 sessions
Approximately 80% of the cases were solved within 20 sessions (Nardone, 1995). The average length of treatment exceeded the standard ten session limit ordinarily imposed by practitioners of the MRI Brief Therapy model, however, considering the poor outcome prognosis commonly experienced by clients with such serious diagnosis, the rate of success demonstrated is particularly significant. Again, note that the foregoing numbers represent the relatively rare clients with extremely debilitating emotional problems that would have typically resulted in hospitalization under conventional diagnosis and care. It is noteworthy that even in cases as severe as these, hospitalization and protracted outpatient counseling (and the consequential dramatic increase in costs) was avoided.
In another report Klaus Pothoff, a psychiatrist in practice in Sweden, described the beneficial results derived from applying the MRI Brief Therapy approach in his clinical practice. Pothoff reports that in Sweden, roughly 50% of hospital beds are found in psychiatric institutions. In 1981 Pothoff assumed responsibility for a psychiatric clinic with 260 inpatients. During the first year, utilizing the MRI Brief Therapy approach, the months-long waiting list for patients needing treatment at the clinic was eliminated. The number of new patients served each year increased from 66 to 222. Within twelve months eighty-percent (80%) of the chronic patients were shown to have been misdiagnosed previously and were able to leave the clinic and return to life within the community (Pothoff, 1995).
The range of presenting complaints presented by clients involved in various outcome studies are widely diverse in nature and intensity from common marital and family difficulties to acute and chronic problems such as anxiety, substance abuse, delinquency, sexual problems, depression, eating problems, school and work difficulties, and schizophrenia. Treatment is effective in terms of complete or significant achievement of the specific goals of behavioral change agreed upon with clients. Defined in these terms, multiple studies demonstrate the approach is effective in approximately 72% of cases (See Weakland, Watzlawick, & Fisch, 1974; Haley, 1980; Nardone, 1995; Soo Hoo, 1995; and Chubb, 1995); and 80% with the solution-focused approach respectively (see de Shazer, Berg, Lipchik, Nunnally, Molnar, Gingerich, & Weiner-Davis, 1986. A recent review of outcome research in solution-focused therapy reported by McKeel (1996), and Dejong, P., Hopwood, L. (1996) report similar, albeit slightly lower success rates (77%) and lend credibility to the outcome reports of other studies described above.
References
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