Effect of Routine Process Monitoring using the ORS / SRS scales on the outcome of treatment by a Rapid Response Team in MHC.

ROZENZWEIG
In 1936 Rozenzweig wrote an article called "Some implicit common factors in
diverse methods of psychotherapy". The article was republished in 2002. He made
a comparison of therapies based on a general theory. He reached the following
conclusions:
- All treatments are about equally effective
- A successful therapy is not equal to a successful theory
- Psychological problems are so complex that all theories contain only one
aspect of the truth.
- A theory to be relevant enough / relevant enough to an aspect of overall
treat psychological problems. If that aspect is changing, change it all.
He came here to his famous Dodo verdict: "All must have prizes". By this he
meant that the various therapeutic forms about all equally effective.

Rozenzweig came to the following ingredients for an effective treatment
1. A therapist with an effective personality
2. A match between client and therapist
3. A systematic ideology relevant enough for the psychological problem of the
client.

The original article was published in 1936. Nowadays it is clear that in any
form of therapy, both universal and specific factors play factors. .

LAMBERT
That various factors play a role in the effectiveness of a treatment is
nowadays beyond discussion. Asay and Lambert were among the first to
distinguish the different factors and their percentages. They made the so
called "Lambert Pie":
• 40% client factors
• therapeutic relationship 30%
• 15% hope
• 15% technology

Lambert (2007) et al also found that the effectiveness and efficiency of the
therapy could be enhanced when therapists got systematic feedback.
Amongst others Wampold and Norcross did further research into this and nowadays
there is most consensus about the vision of Norcross.

Norcross
In 'Psychotherapy Relationships That Work: Therapist contribution and
responsiveness to patients' published in 2002 Norcross came to the following
distribution:
• unexplained 45%
• customer factors, 25%
• therapeutic relationship 10%
• technique 8%
• therapist factors 7%
• interaction of various factors 5%

The beauty of the model of Norcross is that it also takes into account the
interaction of the various factors.

Miller
Duncan, Miller and Sparks investigated, on the basis of the findings of
Lambert, how feedback could be given with as little effort as possible. They
came to several studies and publications and summarized it all together in the
book The Heroic Client (revised in 2004).
Lambert concluded that feedback to therapists benefits the efficiency and
effectiveness of the therapy. Lambert askes his clients to fill in the Outcome
Questionnaire-45 (OQ-45) after each session. This questionnaire measures
symptoms (especially depression and anxiety), relational functioning and work.
Duncan and Miller developed a short scale that correlates strongly with the
OQ-45, the Outcome Rating Scale (ORS).
In addition, they developed the Session Rating Scale (SRS). In this scale
clients are asked about the quality of the therapeutic relationship. They are
asked whether the right issue was discussed, and whether this issue was
discussed in the right way. They are also asked what they found of the whole of
the session in general.
They developed a method they called Client Directed Outcome Informed (CDOI). At
the beginning of each therapeutic session, the client fills in the Outcome
Rating Scale Contact (ORS), and at the end of each session the Session Rating
Scale (SRS). The ORS and SRS each consist of only four items in visual analog
scale. American research has shown that feedback through the ORS and SRS
invreases the effectiveness and efficiency of therapy (Miller et al, 2003,
Duncan et al, 2004).

Hafkenscheid
The SRS and ORS were translated by Anton Hafkenscheid into Dutch (Hafkenscheid
2008).
Hafkenscheid wrote in 2008 in the journal Client-Centered Psychotherapy an
article about Routine Monitoring Process, a systematic method for each session
effectiveness to optimize treatment. Miller et al use the term CDOI, client
directed outcome informed, Hafkenscheid uses this term Routine Process
Monitoring (RPM).
Hafkenscheid compared different feedback methods in his article (CORE-OM,
OQ-45, SESSION EVALUATION Questionaire and the SRS / ORS). It is concluded that
the SRS / ORS best use for this RPM.

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Rapid Response Team
Offering supportive treatment to bridge the waiting time is to my knowledge not
much studied scientifically. Greenfeld (2002) indicates that a delay on therapy
could lead to an increased appeal to health care, higher costs and longer
duration of treatment. There is much scientific evidence for the effectiveness
of a rapid response team within the somatic care. Providing quick treatment
seems also to be examined more in child and adolescent psychiatry (Jones et al
(2000)) than in adult care.

1. Currently, there are a wide variety of therapeutic techniques for specific
patients and certain psychological problems. The guidelines on mental health
care focus only on the specific therapy factors. In addition to these specific
therapy factors also exist universal or non-specific therapy factors. These
factors are a good match between therapist and patient, a good therapeutic
relationship and hope and expectation of improving both the therapist and the
patient
Both universal and specific factors influence the effectiveness of treatment.
Routine Process Monitoring as appointed by Hafkenscheid (2008) is a systematic
method in which feedback is given to the clinician on both the progress of the
client and the quality of treatment. This would optimize the effectiveness.

2. Nowadays mental health care often has waiting lists most often for
psychological and psychotherapeutic treatments. When the waiting time is longer
than 4 weeks it might help to offer those patients some supportive treatment.
They will get 5 supportive treatment sessions offered by a Social Psychiatric
Nurse (SPV) in order to bridge the waiting time.

The primary research question of this study is whether the effectiveness of the
supportive treatment can be increased by the use of RPM
Secondary research question is to what extent the offering of 5 supportive
treatment sessions generally improves the wellbeing of a patient.
The study will take place at Dimence, location Steenwijk, Adult Division. These
are secondary care.

3. Goal
Knowledge:
-Increase knowledge of Routine Process Monitoring as appointed by Hafkenscheid
(2008) on whether or not systematic feedback to supportive treatment leads to
increased effectiveness of therapy.
-Increase knowledge to what extent the offering of 5 supportive treatment
sessions generally improves the functioning of a patient

Utilization:
Patients, health insurers and mental health institutions benefit by optimizing
the effectiveness of mental health care. Patients could benefit by customizing
their treatment. Health insurers benefit as a high efficiency level leads to
increased cost. Metal health institutions benefit by optimizing their
treatment.

All patients who are in treatment by Dimence Steenwijk Section adults fill in
the Outcome questionnaire (OQ-45) before intake.
After the intake, patients are discussed in the team and those with an
indication for psychological or psychotherapeutic treatment are put on a
waiting list. Those patients who must wait for 4 weeks ore more before
psychological or psychotherapeutic treatment can start, will be asked whether
they wish to participate in the study.

Within the study, all patients on a waiting list for a psychology or
psychotherapy are at random divided into three groups:
1. A waiting list group
2. A waiting list group where each individual patient gets 5 supportive
treatment sessions from a social psychiatric nurse
3. A waiting list group where each individual patient gets 5 supportive
treatment sessions from a social psychiatric nurse and is asked for feedback by
the routine process monitoring method.

After about six weeks anyone who will participate in the study will again be
asked to fill in the OQ-45.

All patients who are in treatment by Dimence Steenwijk Section adults fill in
the Outcome questionnaire (OQ-45) before intake.
After the intake, patients are discussed in the team and those with an
indication for psychological or psychotherapeutic treatment are put on a
waiting list. Those patients who must wait for 4 weeks ore more before
psychological or psychotherapeutic treatment can start, will be asked whether
they wish to participate in the study.

Within the study, all patients on a waiting list for a psychology or
psychotherapy are at random divided into three groups:
1. A waiting list group
2. A waiting list group where each individual patient gets 5 supportive
treatment sessions from a social psychiatric nurse
3. A waiting list group where each individual patient gets 5 supportive
treatment sessions from a social psychiatric nurse and is asked for feedback by
the routine process monitoring method.

After about six weeks anyone who will participate in the study will again be
asked to fill in the OQ-45.

The extra burden on all three groups is the single additional completion of
the OQ-45. Completing this takes about 10 minutes. The huge risk is considered
not present.