CDOI Client Example

CDOI Work with the Severely and Persistently Mentally Ill

Joanne is a 47 year-old woman diagnosed with bipolar disorder. When Community Health and Counseling Services (CHCS) began case management with her, she had been in mental health services most of her adult life, and was frequently suicidal. She was in despair, and felt helpless to change it. Charlotte, her Case Manager, had recently been trained in our clinical approach, called Client-Directed, Outcome-Informed (CDOI), which provides a strengths-focused recovery pathway. She asked Joanne to complete a brief measurement tool rating how well she had been doing in the previous week on four scales. Joanne rated herself a 0.8 out of a possible 40, indicating serious distress. Charlotte wanted to validate Joanne’s distress, but she also knew from her training that it would likely be more effective to focus on Joanne’s heroism in the face of such adversity. Accordingly, she pointed out that Joanne was clearly having a tough time, but she couldn’t help but notice that in the Interpersonal area of the measure, she was doing just a little bit better. Charlotte asked how that could be, given that everything else was so distressing for her. Joanne told her that she had been suicidal again the night before, and had discussed it with her husband. He encouraged her by telling her that she was a strong woman, that he loved her, and found her delightful. She disagreed with him, but wanted to be the woman her husband saw her as. Charlotte and Joanne discussed what it means to be a strong person, which led to Joanne’s decision to start an exercise program. She couldn’t see herself as an emotionally strong woman, but she decided to at least become physically strong. They went to a women’s gym, where Charlotte accompanied and supported Joanne, with permission from the owner, until Joanne felt comfortable to go there by herself. One year later, she had built muscle, lost weight, and was no longer suicidal. She was ready to end her case management services. Charlotte remarked that she would not have thought to have that initial conversation with Joanne, or known how to capitalize fully on her strengths, prior to her training in CDOI.

Joanne and Charlotte’s experience together is not unusual at CHCS these days. CDOI de-emphasizes model and technique, as well as so-called "evidence-based practices", in favor of attending to the factors that research has shown to be most important – bringing out the heroism in clients, and the quality of the helping relationship. Working with clients through their preferred method (called the client’s theory of change), and measuring client self-report of progress at regular intervals, with real-time feedback to both clients and clinicians, allows us to partner with clients to note early, small signs of progress or deterioration. Thus, we are in a position to make immediate adjustments in our approach to maximize the likelihood of a successful outcome. The clinical conversations engendered by the use of the measures provide a roadmap to rapid recovery. The use of measurement tools, in combination with our clinical judgment and the continuing input of the client and of others concerned about the client’s well-being, provide a vehicle for determining the efficacy of continuing services. Thus, we are able to closely tailor services to the specific needs of the client, and to make services accountable both to clients and payer sources. This approach is called "practice-based evidence" by developers Drs. Barry Duncan and Scott Miller at the Institute for the Study of Psychotherapy (see for further information about CDOI and Dr. Barry Duncan’s work).

Since implementing CDOI seven years ago, CHCS has reduced length of stay by an average of 60% across programs, the percentage of long term clients in our community support program by 49%, and our client no show and cancellation rates by 30%. Implementation of this approach enabled us to confidently assure our clients that recovery is not just a possibility, but a probability, and it ensures that we are accountable in our use of public funding for mental health services.

CDOI was initially developed for use with an outpatient psychotherapy population. CHCS is the first agency in the world to apply this approach systematically to community support services and group home programs. We are now developing an initiative in which a network of consumers, including those incarcerated, and both inpatient and outpatient providers, join together to bring a collaborative, focused, recovery approach to an entire community. 

Mary Susan Haynes, Ph.D.

Assistant Director for Clinical Services

Community Health and Counseling Services

Bangor, Maine

CHCS Mission

Community Health and Counseling Services will provide community health services that are needed and valued by the communities and individuals we serve.