1. Monitoring in
family therapy
How to stay loyal to our dialogical values?
Karine Van Tricht, Peter Rober & Rolf Sundet
2nd Congress of the Open Network for Dialogical Practices
7-9 March 2013 Leuven, Belgium

2. Measure of process and outcome as
conversational tools: Pathways to a dialogical
oriented practice of service user and therapist
collaboration.
Rolf Sundet
Leuven, 2013
rosundet@online.no
University College of Buskerud,
Institute for Research in Mental Health and Substance Abuse
&
The Ambulant Family Section, Dept of Mental Health for Children and
Adolescents, Hospital of Drammen, Vestre Viken HF.

3. Mental Health Care anno
2013
• Neoliberal society – Market economy
• Economic product
• Profitability
o Money
o Results
o Social benefit
• Psychotherapy
o Evidence based
o Effective
o Efficient
• ‘To measure is to know’ atmosphere
• Quality Control Systems

4. From Evidence Based Practice to
Practice Based Evidence
• RCT’s & Psychotherapy
o Specificity & complexity
o Generalizability?
o External validity?
o Creativity?
• RCT’s & Family Therapy = trouble in paradise
o What is the diagnosis?
o Complexity and specificity of treatment
o Who/what is responsible for change?

5. Monitoring: bridging the gap between
research and practice
• Terminology
o Outcome management
o Routine Outcome Monitoring
o Routine Outcome Measurement
o Feedback Oriented therapy
o Client Directed Outcome Informed Therapy
o Tracking
o Monitoring
o ROMMEN
o QITTEN

6. Evidence
• Outcome improvement
o Duncan & Sparks, 2009; 2010
o Reese et al., 2010
o Anker, Duncan & Sparks, 2009
o Duncan & Miller, 2000
• Drop-out prevention & better dose/effect ratio
o Lambert, 2007; 2010
• Experienced as useful and helpful
o Anker et al., 2011
• Leading to a better working alliance
o Sundet 2010; 2011; 2012

7. Monitoring as a way of working
together
Creating
Feedback
Dialogical
Go with space / Integrating
the flow Culture of feedback
feedback
New way
of
understan
ding
Van Tricht & Rober

8. Sources of inspiration (1)
Client Therapist
System System
Socially, cultural, religious, spiritual
Social (work, education, social
contacts)
The room of the
therapist as a
Family, close friends
dialogical space in
which a multitude of
stories, opinions, em
otions and
perspectives come Therapist(s), couple, parents, children
together
Van Tricht, Van den
Broeck, Rober, 2011; Rober 2012

9. Sources of inspiration (2)
• QIT online (Quality Improvement in Therapy)
Basic Principles Characteristics Instruments
Practice based Multidimensional Psychometrics
Process oriented Multimodal A-theoretical
Feedback driven Flexibel Change sensitive
Broad spectrum Internetbased Clinically
relevant
User friendly
Easily available
Stinckens, Smits, Rober & Claes, 2012

10. A qualitative study of a locally developed family
based practice
within Mental Health for Children and
Adolescents
Conclusions:
Two measures, the Outcome Rating Scale (ORS) and the
Session Rating Scale (SRS):
• They function as intended, that is; as tools of feedback.
• A surplus: They function as conversational tools, that is;
they give rise and opportunity to conservational types
and processes

14. Repairing an alliance burst by means of
discussing feedback

15. Clinical conclusion
The ORS and the SRS do not give
answers, they are opportunities for
questions

16. The family perspective:
The function of ORS &
SRS as conversational
tools

17. To To To To
communicate focus structure explore
To tell and To visualize To give To discover
express direction to
the work
To state areas of To make To state To deepen
acceptance and distinct thematic
change content

18. The Therapist Perspective:
The Function of ORS and SRS as
conversational tools

19. The scales as openings
...for conversations about feedback, progression and
change
...for conversations that express experiences, meanings,
and perspectives about the therapeutic work
...for conversations that create routine and structure
...for conversations characterized by the not-knowing
position
...for externalizing conversations
...for conversations that bring forth a product or result

20. Conceptual Framework QIT Family
Van Tricht & Rober

21. Specificity of integrating monitoring in
Family Therapy
• Instrumental level
o Adult & child versions
o Outcome & process
• Implementational level
o Clear introduction
o In session: Apart / together
o Home work: Apart / together
o On paper or electronic
• Dialogical level
o Open, curious, interested and non-judgmental T attitude
o Feedbackloops: how, what, when
o Enactment

22. Measurements of QIT Family
 [Informed Consent (Van Tricht & Rober, 2013)]
 Concerns Questionnaire (Van Tricht & Rober, 2013)
 SCORE-15 (Fay e.a., 2012; Stratton, subm. in JFT)
 OQ-45 (Lambert e.a., 1996)
 YOQ-30.2 (Burlingame & Lambert, 2001)
 ORS (Duncan & Miller, 2000)
 SRS (Duncan & Miller, 2000)
 (Y)CORS (Duncan, Miller & Sparks, 2003)
 (Y)CSRS (Duncan, Miller & Sparks, 2003)
 TSS(Kokotovic & Tracey, 1990; Tracey, 1989;
Hafkenscheid, 2012)
 IMI(Kiesler, 1996; Hafkenscheid, 2012)

23. Van Tricht & Rober

24. Feedback CULTURE
In the relationship between service user and
therapist, the therapist perspective must be transparent
and the service users perspective is given
priority, especially in situations of no change or
detrimental development
In the relationship between management and therapists
the perspective of managers must be transparent and
the therapist perspective must be given priority in each
actual case.
The function of feedback is dependent upon allowing
the therapists clinical autonomy in order to respond in a
tailored manner to the feedback from the service users.
These measures are in danger of being ruined as
feedback and conversational tools if they are included
in a culture of competition and control

25. Thank you!

26. Alliances in Couple
Therapy
• How to define the alliance in systemic therapies?
• Dyadic relations / additional information?
• Clinical relevance when there’s so much confusion?
• Overall conclusion:
o Positive correlation between working alliance and successful outcome
o Adding one more person adds multiple relationships
Muran & Barber, 2010

27. Alliances in Couple
Therapy
• Individual model of the alliance + relational
dynamics (Couple Alliance Scale, Pinsof & Catherall, 1984)
o Alliances between each client and the therapist
• Direct self-reported alliance
• Inferred alliance (guesses of the qual. & strenght of the partners’ rel. T)
o Alliance between ‘clients-as-a-couple’ and the therapist
o Relational (im)balances
• split alliances/siding/moving toward equilibrium
Muran & Barber, 2010

28. “An emerging quality of collaboration in relation to the
necessary accomplishments, arising from a web of
interacting relational dynamics”
Muran & Barber, 2010

29. A Dialogically
ORIENTED PRACTICE
• including the voice, perspective, idea of the
other, that is; difference is included in the dialogical.
• to respond to the other and be responded by the
other.
• to be embodied and embedded in social
practices, that is; working with and in emotional
transport and relational action

30. The practice
• The use of conversational tools and the weight on
dialogue gives rise to a practice where reflection
and meaning making are intertwined with
emotional and experiential participation of the
therapist
• The centrality of collaboration

31. Collaboration
Collaboration is characterized by;
 Mutualism (turn-taking, jointly responding to the
other’s response, dialogue, conversation)
 Common goal
 Putting difference to work

32. Family based practice
”The helpful ”The helpful ”The helpful
relationship” participation” conversation”
Generating Using professional Asking questions,
collaboration (Alliance knowledge giving time and
and to listen, take structure the work
seriously and believe)
Giving of oneself Understanding Reformulation
through participation
Fighting violation, Having many Giving and receiving
disparagement and possibilities feedback
degradation

33. Publications
Sundet, R. (2010). Therapeutic collaboration and formalized feedback: Using perspectives from
Vygotsky and Bakhtin to shed light on practices in a family therapy unit, Clinical Child
Psychology and Psychiatry, 15(1), 81-95
Sundet, R. (2011). Collaboration: Family and therapists perspectives of helpful therapy. Journal of
Marital and Family Therapy, 37(2), 236-249
Sundet, R. (2012). Therapist perspectives on the use of feedback on process and outcome: Patient
focused research in practice. Canadian Psychology, 53(2), 122-130
Sundet, R (2012). Patient focused research supported practices in an intensive family therapy unit:
What happens? Journal of Family Therapy, (Accepted for publication).
Sundet, R. (2012). Postmodern-oriented practices and implementation of patient-focused research:
Possibilities and hazards. Australian and New Zealand Journal of Family Therapy (In review).