Dr. Barry Duncan presented the keynote speech this past weekend at the Harvard Medical School and Cambridge Health Alliance conference on “Treating Couples.” Over 300 professionals attended this prestigious event on couples therapy chaired by Drs. Judy Platt, Jill Harkaway, and Elizabeth Brenner.
In his keynote, Dr. Barry Duncan presented the results of the Norway Couple Project, an introduction to the Partners for Change Outcome Management System (PCOMS) applied to couples, and a brief overview of how to use data to track and improve outcomes at individual and agency levels. Here is a summary of Dr. Barry’s keynote presentation, which focused on the largest set of studies ever done of couples therapy, the Norway Couple Project.
8 LESSONS LEARNED FROM THE NORWAY COUPLE PROJECT
- Use valid, feasible instruments to routinely monitor client progress and the therapeutic alliance to increase the chance of a positive outcome. Our replicated couple findings support a growing body of evidence that outcomes are enhanced when therapists systematically monitor treatment response.
- Monitor the therapeutic alliance at each session. The Project findings joined the extensive ranks of couple and individual studies confirming the link between the alliance and outcome. According to our findings, therapists stand to increase their chances of success in couples therapy by tracking alliance scores from the first session onward, with the goal of increasing lower scores, particularly by session three. Our finding that therapist average alliance quality accounted for 50% of the variance among therapists regarding outcome underscores the crucial role of this factor in couples therapy. Knowing how well each partner is engaged in the process and connected to the therapist at each meeting can help therapists negotiate this delicate equilibrium.
- Determine each partner’s goal for seeking therapy early in the treatment process. We found a direct relationship between couple goals at the beginning of therapy and outcome. Whether both partners sought couples therapy to strengthen the relationship or to clarify it or whether each had different goals for seeking help made a significant difference, on average, in whether the couple would be together 6 months beyond therapy. Early goal identification can assist therapists to work toward client-defined better futures, whether that means couples remaining together or apart.
- Use valid outcome instruments, not only relationship status, to determine treatment success or failure. We found that, all clients, on average, benefited from treatment, regardless of relationship status at termination or follow-up. Individual rather than couple outcomes may be better markers of success in couples therapy. That is, couples may dissolve, but one or both partners may view this positively. Individual measures of progress can facilitate a correct determination of actual outcome, even in instances of separation or divorce.
- Gain experience working with couples. We found that therapist experience working with couples makes a difference in outcomes. Beginning therapists can seek supervision from experienced couple therapists to develop the skill set required to manage a couple session, likely including how to moderate conflict and direct in-session interaction. More experienced therapists can add more couples into their caseloads, providing the training ground for improvement. Learning from that experience is key. We advocate that therapists monitor their experience with feedback, allowing a process of continual reflection and learning.
- Men’s alliance scores were a stronger predictor of outcome at post-treatment than women’s, a finding similar to that in previous studies. The consistency of findings pointing to the importance of men’s connection to the therapist and the therapy process invites therapists to meaningfully involve men early and throughout treatment.
- Become skilled at incorporating task activities, including structuring, directing, and giving input as appropriate. Our findings indicate that many couples, while appreciative of therapist relationship skills, wished their therapist had been more active. This may be particularly salient in couples therapy as therapists may need to interrupt negative communication interchanges between couples to establish a climate of safety and one different from that typically occurring outside of therapy. The ability of the therapist to construct this type of experience for the couple may enhance hope and play a role in actively teaching couples how to communicate more effectively. More training may be required for therapists to comfortably assume these types of in-session activities.
- Maintain contact with couple clients between sessions as necessary and be flexible in scheduling. Many couples reported feeling dissatisfied that their therapists were not responsive to their needs to reschedule appointments or be available for contact between sessions if requested. Therapists may be so focused on in-session process, they fail to consider the implications of “nuts and bolts” service delivery for the alliance. Policies could be instituted that encourage therapists to resolve scheduling difficulties and be flexible in accommodating client wishes for more or fewer meetings.
WHY PCOMS FOR COUPLES THERAPY?
PCOMS is not a rote measure administration; it is a light-touch, checking-in process via the Outcome Rating Scale (ORS) that serves as a basis for beginning conversations. With PCOMS, client involvement is routine and expected; ORS scores are openly shared and discussed immediately after they are collected. Given the transparency of measure scoring and subsequent discussion, the system provides a client-defined, mutually understood reference point for reasons for seeking service, progress, and engagement. Open-ended visual analog scales allow clients to rate their global levels of distress without the constraints of theory or therapist-derived content domains. Specifics of that distress unfold as clinicians invite clients to give meaning to their scores. From this starting point, the clinical conversation evolves into a specific client-defined representation of the reason(s) for service.
PCOMS represents a departure from expert-driven formulations that attempt to classify client distress and problems of living from a theoretical or symptom vantage point. Instead, clients are empowered to highlight their views of distress/well-being, refocusing therapy toward individualized problem construction and solution building and away from options based on diagnosis, symptomology, or normative functioning. Unlike other validated outcome instruments, the ORS is not a list of symptoms or problems checked by clients on a Likert scale; it is not forced choice or symptom oriented. Rather it is an instrument that is individualized with each client to represent his or her idiosyncratic experience and reasons for service.
A major value of PCOMS in systemic work is its capacity to initiate conversations about discrepant views in objective, non-blaming ways. The therapist’s inquiry about the differences in ORS scores sets the stage for developing mutual goals and a means to measure success. Effective navigation by the therapist of couple alliance differences should be reflected in Session Rating Scale (SRS) ratings, allowing the therapist a chance to recalibrate ongoing work accordingly.
The transparency of the PCOMS process establishes a space where all views are respected and meanings are co-explored; continuous responsiveness to clients’ unique views, grounded in valid, objective data, fosters dialogue, the emergence of mutual solutions, and a built-in safety net for avoiding failure.
The first step is to track your outcomes and career development and take it on as a project. Proactively monitor your effectiveness in service of implementing strategies to improve your outcomes. Practice the skills of your craft and monitor your results. Second, pay close attention to your current growth. Take a step back, review your current clients, and consider the lessons you are learning, especially from those who are not benefiting. Articulate how client lessons have changed you and your work and what it means to both your identity as a helper and how you describe what it is that you do.
Next, deliberately expand your theoretical breadth—loosen your grip on the inherent truth value of any given approach. Take multiple vantage points on your journeys with clients while you search different understandings of client dilemmas. Fourth, reflect about your identity and construct a story of your work that captures what you do as a helper.
Learn how to implement PCOMS in your agency by attending the Training of Trainers Conference, January 27-30, 2020 in West Palm Beach, Florida.
Get all the articles in the Norway Couple Project at: https://betteroutcomesnow.com/resources/articles-handouts/
For a .pdf of Dr. Barry Duncan’s presentation slides, please email: firstname.lastname@example.org