Division of Behavioral Health Services

Best Practice Advisory Committee: Client Directed, Outcome Informed Practice (CDOI)

Over the last seven years, Scott Miller, Ph.D. and Barry Duncan, Psy.D. have been working to develop a valid, reliable, and feasible system for measuring psychotherapy treatment outcomes.  From this work has come the Client Directed Outcome Informed approach (CDOI).

The approach is based on two consistent findings from the research literature:

  1. Clients' ratings of the therapeutic relationship have a higher correlation with engagement in and outcome from psychotherapy, than the ratings of therapists.
  2. A client's subjective experience of change early in the treatment process is one of the best predictors of outcome between any pairing of client and therapist, or client and treatment program.

Given these facts, using the CDOI approach, a client is asked to complete two very brief, but formal scales at each therapy session. The first is the Outcome Rating Scale (ORS) given at the beginning of each session to measure the client's experience of change or progress between visits. The second, called the Session Rating Scale (SRS) is completed at the end of each session and measures the client's assessment of the alliance. Each scale is comprised of four questions and the entire process takes only 2-3 minutes per visit. The fact that each of these scales is used at every session allows the therapist to change approach or style during therapy if a negative experience or poor progress is reported by the client. Research shows that this greatly enhances the likelihood of a positive outcome.

The CDOI approach has been demonstrated as effective in the improvement of outcomes, such as retention and client reported improvement, in several treatment settings in the United States. Studies indicate that counselors are able to enhance client engagement in treatment, build stronger alliances with clients and families, and achieve substantially better outcomes. The approach may be particularly effective when utilized for Substance Abuse treatment where research consistently points to client retention as the single most important factor is successful treatment outcomes.

A Client Directed, Outcome Informed approach to behavioral health treatment fits well with the Arizona Principles regarding "voice and choice". The CDOI approach can be utilized with nearly any treatment modality for individuals (the ORS and SRS have been adapted to family and group therapy, and studies of it's effectiveness in those forms of treatment are underway) and can therefore be adopted by most agencies.