The dangers of presupposing someone is in denial

I belong to a listserve composed of psychotherapists who are interested in the development, understanding and promotion of client directed outcome informed therapy (CDOI).  It is called the heroicagencies listserve, and I plan to share excerpts of listserve posts occasionally on Diddly becuase they are often really well written and interesting. You can learn more by going to   CDOI is not a model of therapy, such as cognitive behavioral therapy, but an approach that attempts to priviledge the therapy client’s voice by systematically collecting information each session from clients about their how well they are doing , and how they well they think the session went. We use brief scales to do this. The Outcome Rating Scale (ORS) measures how well they are doing. Scores range from 0-40, and scores below 25 indicate clinical levels of distress. In other words, scores above 25 indicate that the client is not going to show the same benefit from therapy as clients below 25 will show. They are actually at a higher  risk of deterioration. We hold 25 to be ‘the clinical cutoff’.

So do what do we do when someone shows up for therapy and scores 25 or above? Do we therapists call it ‘denial’?  Barry Duncan wrote a great post on the subject that appears below:

This is a great discussion about clients coming in over the cutoff—many valid points of few. But let me throw in a word of caution regarding people getting “more real” as time goes on. With folks who score over 25, caution is warranted about any approach that focuses on matters other that the issues at hand. Why? People who come in over the clinical cutoff are, on average, at a higher risk of deterioration. Think about it. What do we often do with folks who think they are doing well? We put on our Wicked Witch costume, suddenly growing warts and a humongous nose, and we stir the cauldron. Laughing devilishly as we are stirring the steaming brew with large strokes, we shriek, “Oh you think things are going okay do you, we’ll see about that, my pretty!” So are they getting more real, or are they accommodating the therapist’s view that they must be doing worse than they are reporting? This is especially true with mandated folks. I am not saying it never happens. I am just saying that we should use caution and ask ourselves this question. Often people score high because they are truly not in distress. Someone else might be.

Here is I wrote about this issue recently:

Given that the first ORS provides the comparison point for all future work with the client, it is essential to get a good rating. This means striving to get the best, most accurate rating of the clients experience possible, a sincere appraisal of his or her life at that moment. I encourage a frank discussion of the issues involved, express my desire to be helpful, and hopefully get the idea across that therapy works best when the ORS accurately reflects how his or her life is going

I have had clients who rated way over the cutoff and then after a few minutes start telling me how badly their life is going. I then pick up the measure and express my confusion about their rating, which often leads to a different rating in the first session. For example, I saw Darrell, a referral from the DUI who rated himself a 36.8 on the ORS. This is not just doing good—this is doing DAMN good. Very, very few people score this high. But I took it in stride and merely commented on how well he was doing, especially considering his recent arrest. When I asked him how the referring PO would rate him, he told me he did not give a flying f..k about what his PO thought.

After a while of talking about things he lightened up with me when he figured out that I was on his side. He told me that his girlfriend kicked him out and that he had been sleeping in his truck. After commiserating a while, I asked him to help me understand how his life could be so hard while his ORS looked like he just won the lotto and spent a week in Hawaii with Angelina Jolie. He laughed and told me that he was pissed off in the beginning and rated the ORS without thinking much about it. I asked Darrell if he would do it again because it would help us keep track of our work together and make sure he was getting where he wanted to go. And he did. His score was 18.3. And when he decided to quit drinking, his partner joined him in therapy.  Sometimes you have to work at that first ORS—to build a culture of feedback and secure a good rating that reflects what is going on in the client’s life. It is worth the effort.

But please take the client at face value unless you have evidence, from them, to the contrary. Err on the side of believing that there is a good reason for the client to rate it as they did. All you have to do is explore the client’s experience—ask them—to figure out the context for the score. Consider Yvonne, an 18 year old woman in a CD unit that specialized in working with homeless young women. Yvonne consistently scored the ORS above 30 while also detailing problems in her family and struggles with finding a job. This was perplexing to the staff (she couldn’t be doing that well) so they asked me to do a consult. Once again Yvonne scored high, a 34.6, and once again conversation quickly drifted to problems she was having with her mother. After hearing her out and exploring the concerns she had in her relationship with her mother, I asked Yvonne about her ORS score (warning: reader discretion is advised—frank and explicit material…):

Barry: Yvonne, as I mentioned earlier, your score on the ORS was very high indicating that you are doing very well, and that’s great. But I was wondering how that fit with the conversation we just had, which seems like you have been hurting quite a bit about your relationship with your mother—and you scored high on that scale as well. Can you help me make sense of it? 

Yvonne: Sure, and that’s what they don’t get around here, that I could be doing so well given everything that has happened to me in my life, addicted to crack, living on the streets, being a whore, and all. But you see, my life is great now compared to where it was. I am straight for the first time in 6 years. Just 4 months ago I was blowing every swinging dick I could for crack. I lived in the most disgusting of circumstances, f..ked the most vile creatures on earth, and didn’t care about anything—mostly myself! But look at me now—I have a chance, I have a chance for a different life. And I have a chance to address the shit with my mom. .

Barry: Thanks Yvonne for helping me understand this. It makes complete sense to me now. It’s like you are saying that you always have to know what you are comparing it to. And for you, now, even with problems in your life, compared to what it was, is, essentially no comparison!

Yvonne: You got that right!

Transparency is the rule. Just ask clients for help if it doesn’t make sense to you. It usually makes sense to them. And even if it doesn’t make sense to you, take it at face value.    (END POST)




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