measure data in this way. In my (Rob) own practice I have identifi ed some generic skills I wish to develop – particularly how I start and end sessions – as well as some more specifi c narrative therapy skills. Because both the sessional measures and the deliberate practice framework are trans-theoretical, colleagues are using them to inform their own development within a range of therapeutic approaches. It is however important that membership of


Box 4


as tawdry as bureaucracy. Again, our approach to this has been emphasising, in the stories we tell of our practice, what the measures have contributed in terms of a collaborative therapeutic alliance over any data collection aspects. We have endeavoured to keep the


conversations going about the measures as much as we can and in multiple contexts – formal meetings, supervision and informal discussions – always with an emphasis on appreciation, positivity and curiosity. Also, as we will share below, we have consulted the team formally regarding their feedback on the whole process (Box 3).


Production position From the production position, we have


sought to share and discuss our outcomes with a range of stakeholders. This is the position in which reductionist, decontextualised data are required. Our data now demonstrate, for the fi rst time as a department, that we are eff ective in what we do: • our average eff ect size is similar to the “industry standard” of 0.8 (arguably quite an achievement in the context of the chronic and often declining physical ill health of our clients); • we make a clinically signifi cant diff erence to our clients within very few sessions and the work is usually concluded within around eight sessions. Such outcomes are sustaining of


staff members as well as convincing to commissioners, referrers and Trust managers. Summaries have been provided and conversations invited in various contexts both within and beyond the trust. We can now produce graphs to demonstrate our eff ectiveness (Box 4). As the database increases, we are able to demonstrate eff ectiveness within individual


40


clinical services – for example, we can show our work with people with diabetes is eff ective in improving psychosocial functioning, alongside activity data and “harder” clinical outcomes such as signifi cant mean reductions in blood glucose. Our clinical services are commissioned individually, so service-specifi c data are vital in contract renegotiations.


Consultant position From the consultant position, we have been


interested to consider how these measures and the data they generate might be used to inform professional development and the overall development of the department. At the level of individual clinician


development, these data can be highly useful. In the broadest sense, outcome and session rating scores can be used both to inform which clients to take to supervision (that is, those at risk of poor outcome, as indicated by stalled progress, deterioration or a struggling therapeutic alliance) and which aspects of the work to attend to (such as family functioning rather than individual wellbeing). Developments in the study of excellence


in diff erent domains of professional practice have been applied recently to psychotherapy (Rousmaniere, 2017; Rousmaniere et al., 2017), and suggest some more innovative ways such data can be used in supervision. Rousmaniere and colleagues have articulated a cyclical model of deliberate practice for psychotherapy based on a the combined use of sessional measures, feedback and video- recordings of sessions, reviewing these with a supervisor in order to identify highly specifi c goals for skill development, then working in a focused way to develop these skills and assessing outcome through ongoing review of feedback measures and video review. We have formed a “deliberate practice group” in the department with a view to using the outcome


the deliberate practice group is optional too – again a “coalition of the willing”. In its original formulation, the deliberate practice model can be seen as consistent with the neoliberal agenda – promoting the entrepreneurial self, the imperative of continuous self surveillance and self improvement (Miller & Rose, 2008). Clearly this can be oppressive, perhaps, particularly if staff are incited to measure themselves against an external criterion of success and to seek to close the gap (White, 1997; White, 2002). Our colleagues are no “docile subjects” however, and there is a proliferation of practices of engagement with these ideas in ways that are more consistent with a rigourous refl ective practice than a self-subjugation. We seek to embrace this work as an “anti-perfection project” (Reynolds & polanco, 2012). At the level of departmental development


the data can be highly useful too. In addition to the department-wide outcomes, it is possible to examine outcomes by clinical specialty and various client demographics. We know, for example, that our outcomes are not as good in our work with South Asian clients. We have excellent examples of culturally-appropriate services within the department (such as a group for Urdu-speaking parents of children with neurodevelopmental diffi culties) that we can learn from. We can now compare our outcomes in


increasingly nuanced ways – younger vs older Asian women for example – and respond accordingly at a departmental level, such as making connections with a local mental health group for older South Asian women to see what we can learn from them and how we might best collaborate.


Final refl ections Overall, the process of establishing and


consolidating the use of sessional measures has been successful. We now have hard evidence for our eff ectiveness where before we had none and we have achieved this in a way that has neither involved reproducing pathologising discourse, nor led to an exodus of staff from the department.


Context 170, August 2020


Refl exive positioning as a tool for organisational change: Systemic approaches to implementing outcome measurement


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