Outcome Orientated-CAMHS: A whole
service model for CAMHS
Sami Timimi
Dangers of Commodification
• 
• 
• 
• 
• 
“Branding” leads to abstraction, alienation and short
termism.
Mental health always in danger of approaches being
‘commodified’.
Need to struggle to remain reflective, curious,
grounded, and transparent.
Difference between resistance to change and critical
engagement.
Adoption of OO-CAMHS or similar should be
adapted to each clinician and each team.
Which has the largest impact on
outcomes?
A.  Extra-therapeutic factors (such as Socio-economic status, level of
education, social capital).
B.  Matching treatment to diagnosis.
C.  Therapeutic alliance.
Do any of you use outcome
measures to inform in an on-going
way treatment decisions?
Do you think feedback on
progress effects outcomes?
A. Yes.
B.  No
Which model?
•  Since the 60 s, the # of models has grown
from 60 to over 400, multiplying like…
•  Each claims superiority in
conceptualization and outcome
•  The result is a fragmentation along
theoretical and disciplinary lines
•  Now over 100 so called evidence based
treatments-effectiveness not increased in
40 years, and…
Evaluations of Treatment Models
•  With few exceptions, partisan studies originally
designed to prove the unique effects of a given model
have found no differences -nor has recent metaanalyses.
•  Termed, the Dodo Verdict •  Everybody has won and all must have
prizes.
Meta-Analytic Research
•  Client/ extra-therapeutic factors
biggest effect
•  54% of treatment effects due to
alliance factors
•  8% of treatment effects due to
model and technique
The dodo wars ESTs v CFs
•  Little disagreement that overall Common Factors (CFs)
convincingly defeats Evidence Supported Treatments
(EST)
•  Continuing debate about specific ‘problems’ e.g.
Trauma, panic.
•  Debate about client characteristics e.g. Do we need to
be more selective about psychodynamic therapies?
•  Onion v garlic problem. Who wants change? E.g.
involving parents in working with childhood behaviour
problems/ eating disorders.
•  Many treatments (e.g. NLP, gestalt) have not been
subject to proper outcome research, should we trust
them?
Dodo bird verdict holds for children
•  Meta-analysis of treatments for childhood MH
problems finds meagre differences (.2 ES) between
approaches.
•  Behavioural approaches in direct comparison to other
bona-fide child treatments offer no advantage.
•  There is little differential efficacy between approaches
to marriage and family therapy.
•  Aug 04 Depressed Adolescents Respond Best to
Combination Treatment TADS. Compared Prozac,
Placebo, CBT, CBT+Prozac. Lack of advantage of
placebo, 6v2 suicide attempts. Follow up 6 months –
group differences disappear but increase risks with
medication.
•  MTA study: 14 month stimulants, BT, BT+stimulants,
comm care. 1999 treatment with stimulants should be
first line for ADHD . Differences disappear by 3 years,
but increase risks with medication.
Therapy for children and families!
• 
Better outcome found when parents/carers included,
particularly for behavioural problems.
• 
Therapeutic alliance with parents AND children
additive. Maybe more important in behavioural
disorders.
• 
Group therapy for young people with behaviour
problems can make it worse.
• 
Extra-therapeutic factors have largest impact on
outcome.
• 
Poverty, parental mental health problems/criminality,
single parent status, callous/unemotional child all
predict poor response to parenting programmes.
So that s what the research says - so what?
OO-CAMHS"
Partners for Change Outcome Management Systems
(PCOMS)
•  Michael Lambert first used client feedback systems in late 1990s. Using the Outcome Questionnaire 45.2, Lambert has conducted five RCTs and
all five demonstrated significant gains for feedback groups over treatment as usual (TAU) particularly for clients at-risk for a negative
outcome.
•  The development of PCOMS included research, and publications in peer reviewed journals to establish the psychometric validation of its
instruments. The ORS and SRS scores exhibit good internal consistency and test-retest reliability despite the ultra-brief nature (four items) of
these measures. PCOMS has been shown in a number of randomized clinical trials to significantly improve engagement and
effectiveness in real clinical settings (community mental health, marital counselling).
•  Community Health and Counselling Services provides community-based home health and mental health services to adults and children in Maine
(over 750 clinical staff): Reduced the number of patients seen for more than one year from 655 (pre-PCOMS) to 321 (post-PCOMS).
Reduced the number patients seen more than two years from 227 (pre-PCOMS) to 94 (post-PCOMS). Reduced number of No Shows
by 30%.
•  Southwest Behavioral Health Services provides comprehensive behavioural health services in Arizona (over 400 clinical staff):
Decrease in the
average length of an episode of care in children s services from 315 days to 188. Adult services length of stay decreased from an average
322 days to 158. No shows decreased by 47%.
•  Center for Family Service of Palm Beach County, Florida provides counselling, early child education and homeless services (over 100 clinical staff):
Reduced drop outs by 50% and no shows by 25%. Using 40% fewer sessions to achieve program goals. Use of fewer resources without
sacrificing client satisfaction. Decreased by 80% the number of long term therapy cases where no benefit was being achieved. Decreased the
number and frequency of client grievances and complaints to almost zero. OO-CAMHS"
What else is out there?
•  John Weisz:
the very real-world factors that experimentalists might view as a nuisance (e.g., child comorbidity, parent pathology,
life stresses that produce no-shows and dropouts, therapists with heavy caseloads) and thus attempt to avoid (via exclusion criteria) or
control, are in fact, precisely what we need to understand and address to make psychosocial treatment protocols work in real clinical
practice
•  Len Bickman:
Fort Bragg and Stark County studies in both studies the amount of treatment did not affect outcomes. Supported by
other reviews of community-based treatment, the evaluators concluded that there was no evidence that the treatments as provided in the
real world were effective for children and adolescents.
•  Peter Fonagy:
UK bottom of the league table for most indicators of childhood emotional well-being in developed countries, yet
top spender per head of population on CAMH services
•  Bury IAPT: Using SDQ and CORE-OM session by session
•  Hertfordshire: Using SDQ and 3 goals session by session.
.
OO-CAMHS"
OO-CAMHS: A whole service
model for CAMHS
Listening to patients and optimising outcomes
OO-CAMHS"
A whole service model for a culture
change
•  CONSULTATION: Extra-therapeutic factors: Professionals meetings to avoid duplication and address
external factors before starting therapy. Involve family in reviewing social circumstances.
•  OUTCOME: Monitor outcome session-by-session to alert early to poor response. If no change by
session 5, review with patient and MDT. •  RELATIONSHIP: Monitor the alliance session-by-session.
•  ETHICS OF CARE: Whole team ethos. Like patients, clinicians need to feel listened to, respected and
supported. Helps improve each clinician s therapeutic potency . New Paradigms
Move away from • A focus on matching a treatment plan to a diagnosis. • Focusing on what is wrong. Suffering must be validated, but an emphasis on dysfunction can distance from resources and resilience factors. • Thinking in terms of pathology . Instead use the potentially less stigmatising problems . • Blaming and berating people for the problem. Self-­‐blame and self-­‐loathing are unlikely to lead to positive action. • Acting the expert . Patients are more likely to maintain changes they experience as being down to their doing something to change. • Creating patient dependency on services. Help patients Cind resources in themselves and their communities. Recovery is a journey rather than treatment . • Paperwork and bureaucracy that has no evidence base that it improves patient outcomes or safety. New Paradigms
Move toward • Recognising that our treatments are not as important as extra-­‐therapeutic factors. Understand the real life context that people live in. • Fostering on-­‐going partnerships with patients. Our most important task in treatment is to learn about each person s unique belief system and treat it with respect, paying particular attention to their cultural models • Believing that everyone is capable positive change. • Allowing patients to make choices and to be responsible for those choices. • Structuring treatment around patients goals and expectations. • Believing that patients know what s best for their own lives and have the motivation and capacity to reach their goals. • Understanding the complexity (and messiness) of mental health work. OO-CAMHS"
Consultation
• 
Rationale: 40-85% of variance of outcome accounted for by extra-therapeutic factors such as social support, parental mental
health, socioeconomic status and motivation. This should make us take seriously the de-centring of our (and our treatments)
importance to the process of change.
• 
Before embarking on treatment think about the external factors/system around the child.
• 
No more than one agency working on any one problem at any one time.
• 
Who already has an attachment or important relationship with the young person particularly when that person already has other
agencies involved in their care.
• 
Who has the motivation to change?
• 
Establish whether there is a stable predictable set of circumstances before embarking on treatment.
• 
Families in crisis: avoid over-intervention.
OO-CAMHS"
• 
• 
• 
• 
• 
• 
• 
• 
• 
Outcomes
Rationale: Session by session monitoring of outcomes. Regular feedback to the patient on their progress can by itself improve
outcomes. If the outcome is showing no signs of improvement after 3-6 sessions, there is a high risk of a poor outcome. Change
as a result of an intervention usually happens early in treatment. Matching the treatment model to a diagnostic category has a
clinically insignificant impact on outcome.
Patient Related Outcome Measures - PROMs. The measure should be simple and feasible otherwise it won t engage clinicians.
Keep the service focussed more on providing treatment to improve outcomes (rather than assessments).
If the young person or their parents rate above the cut off for clinically significant impairment at first session, discuss.
Use the PROM actively to help shape the intervention.
Keep a record of the outcome score session by session and plot a graph that is discussed at the beginning of each session.
If no improvement has occurred after 5 sessions discuss with the young person and/or their parent/carer and/or the
Multidisciplinary team.
Maintenance of change after therapy is associated with patients ascribing change to something they did.
Once the young person and/or their parent/carer are scoring above the cut-off for clinical significance for 2 sessions discuss
discharge.
OO-CAMHS"
Relationship
• 
• 
Rationale: Alliance as rated by the patient is by far the strongest factor, from those within treatment, associated with improved
outcomes.
Measure the alliance at the end of each session. Make sure the measure is simple and feasible otherwise it will not engage
clinicians.
• 
From the first session create a culture of strong interest in patient feedback.
• 
Building strong alliances is important particularly early in treatment.
• 
Look for any minor variations on alliance feedback.
• 
Address and discuss alliance issues before the young person and/or their parent/carer leave every session.
OO-CAMHS"
Ethics of care
• 
• 
• 
• 
• 
Rationale: Team effects are often found in outcome studies. Using the database associated with the PROM, means there is
clinician by clinician outcome data available. If this is not handled sensitively it can become a source of anxiety for clinicians
rather than a source of empowerment. A clinician anxious about their place in a team is more likely to perform poorly.
Putting patients strengths, abilities and choices in the centre of the therapeutic process needs clinicians who similarly feel
empowered by having their strengths, abilities and therapeutic choices noticed and respected.
Strong team relationships makes it easier to fail successfully as a clinician and pass the patient who is not improving to another
clinician in that team.
Each clinician is different. Team consultants, managers and supervisors have an important role in noticing and re-enforcing each
individual clinician s strengths and helping them develop their therapeutic skills through that clinician s choices.
Good therapy sees positive value, strengths, acceptance, and abilities in their patients. Good teams see positive value, strengths,
acceptance and abilities in their clinicians.
Database of outcomes
OO-CAMHS"
Evidence base everything!
•  Data for each patient, each clinician, each team.
•  Constant feedback helps think about practice, areas for improvement
and how well we are doing too.
•  Team can publish its outcomes, helping patients understand what they
can expect.
•  Any new initiative (e.g. Multi-Family group, Nurtured Heart Approach
group) can be evidenced.
OO-CAMHS"
Thank you for listening
The OO-CAMHS Team-
Professor Sami Timimi: Consultant Child and Adolescent Psychiatrist and
Developer of OO-CAMHS
Dianne Tetley: Assistant Director of Research and Effectiveness and OOCAMHS NHS management support.
Gill Walker: Nurse therapist and OO-CAMHS project facilitator. Dr Amulya Nadkarni: Consultant Child and Adolescent Psychiatrist and
clinical director providing support for roll out/implementation trust wide.