SoYouWantToBeABetterTherapistSlides

www.heartandsoulofchange.com 7/22/2010

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Barry Duncan, Psy.D. www.heartandsoulofchange.comBarry Duncan, Psy.D. www.heartandsoulofchange.com954.721.2981 www.whatsrighwithyou.com954.721.2981 www.whatsrighwithyou.com

[email protected]@comcast.net

On Becominga Better Therapist

So You Want to BeA Better Therapist


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Winter Getaways!Advanced TrainingsWinter Getaways!

Advanced Trainings CDOI Clinical Work: Becoming a Better

Therapist—January 19-21, 2011 (18hours of CEs)This 3 day intensive course is designed totake you to the next level of CDOI practice,as well as helping you become proactiveabout your development as a therapist. Itgoes way beyond the basics and includes livedemonstrations with clients.HSCP Training of Trainers (TOT):January 24-28, 2011 (24 hours of CEs)This intensive training experience intends togive you all you need to begin training othersin CDOI and/or implementing CDOI in youragencies. And it provides the first step inbecoming an HSCP Certified Trainer of CDOI.

CDOI Clinical Work: Becoming a BetterTherapist—January 19-21, 2011 (18hours of CEs)This 3 day intensive course is designed totake you to the next level of CDOI practice,as well as helping you become proactiveabout your development as a therapist. Itgoes way beyond the basics and includes livedemonstrations with clients.HSCP Training of Trainers (TOT):January 24-28, 2011 (24 hours of CEs)This intensive training experience intends togive you all you need to begin training othersin CDOI and/or implementing CDOI in youragencies. And it provides the first step inbecoming an HSCP Certified Trainer of CDOI.


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Starts With Our ClientsMy First Client, My First Story

Starts With Our ClientsMy First Client, My First Story

In my first placement atthe state hospital.

Tina was like many:young, poor,disenfranchised, heavilymedicated, & on themerry-go-round ofhospitalizations and atthe ripe old age of 22,she was a “chronicschizophrenic.”

In my first placement atthe state hospital.

Tina was like many:young, poor,disenfranchised, heavilymedicated, & on themerry-go-round ofhospitalizations and atthe ripe old age of 22,she was a “chronicschizophrenic.”

Learning from Our ClientsThanks Tina

Learning from Our ClientsThanks Tina

So Tina started mypsychotherapy journey andoffered up my first lessons:authenticity matters andwhen in doubt or in need ofhelp, ask the client. Whereever you are Tina, thanksfor that great start.

And we sure need their helpto improve…

So Tina started mypsychotherapy journey andoffered up my first lessons:authenticity matters andwhen in doubt or in need ofhelp, ask the client. Whereever you are Tina, thanksfor that great start.

And we sure need their helpto improve…


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PsychotherapyThe Good…

PsychotherapyThe Good…

Study after study,Study after study,and studies ofand studies ofstudies show thestudies show theaverage treatedaverage treatedclient is better offclient is better offthan 80% of thethan 80% of theuntreated sample.untreated sample.

PsychotherapyThe Bad…

PsychotherapyThe Bad…

Drop out ratesDrop out ratesaverageaverage 47%47%

TherapistsTherapistsvary… a lotvary… a lot


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TDCRP: top thirdpsychiatrists giving placebobested bottom third givingmeds; clients of besttherapists improve 50%more & dropped out 50%less; meds useful for clientsof more effective therapists,not for less. Wampold, B., & Brown, J. (2006). Estimating variability in

outcomes attributable to therapists: A naturalistic study ofoutcomes in managed care. Journal of Consulting andClinical Psychology, 73 (5), 914-923.

Therapist DifferencesIncredible Variation Among Providers


And the UglyProviders Don’t Know

And the UglyProviders Don’t Know

20-70% range

Therapists graded theireffectiveness, A+ to F—67% said A or better;none rated belowaverage.

Therapists don’t knowTherapists don’t knowhow effective they arehow effective they are

Surprising given…

20-70% range

Therapists graded theireffectiveness, A+ to F—67% said A or better;none rated belowaverage.

Therapists don’t knowTherapists don’t knowhow effective they arehow effective they are

Surprising given…

Hansen, N., Lambert, M., Forman, E. (2002). Thepsychotherapy dose-response effect and itsimplications for treatment delivery services. ClinicalPsychology: Science and Practice, 9, 329-343.

Sapyta, J., Riemer, M., & Bickman, L. Feedback toclinicians: Theory, research, and practice. Journalof Clinical Psychology: In Session, 61, 145-153


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We Just Want to Help People

• 17,000 clinical hours ago, Iwas a starry eyed newtherapist….and

• As a trainer, I have rubbedelbows with thousands oftherapists & the thing thatstrikes me most is theirauthentic desire to behelpful.

Golly! I just wantto help people

Becoming BetterI Want To Help People

• The majority of us wantto be helpful. Andalways have—manyanswered “I want to helppeople” on school apps.Dissuaded from thatanswer…notsophisticated andappeared too “co-dependent.”


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Becoming BetterAfter All

There is not muchfinancialincentive—wedon’t do this workbecause wethought we wouldacquire thelifestyles of therich and famous.

Becoming Better at What We DoMore of a Calling

• That smart, creative indvsmake the sacrifices foradvanced degrees only toearn far less than otherssays something

• Required servitude w/othe promise of rags toriches only makes senseb/c it is more of a callingthan a job—a quest formeaning & fulfillment


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But How Do We Get Better?But How Do We Get Better?

Question #1:Question #1:

Finding the rightFinding the rightapproach orapproach orselecting evidenceselecting evidencebased treatmentsbased treatmentswill improvewill improveoutcomesoutcomes

FalseFalseStudy after study, andStudy after study, andstudies of studiesstudies of studiesshow that allshow that alltreatments are thetreatments are theright treatmentright treatment——forforsome clients.some clients.

How Do We Get BetterPop Quiz



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The Dodo VerdictThe Dodo Verdict

••With few exceptions, partisan studiesWith few exceptions, partisan studiesdesigned to prove the unique effectsdesigned to prove the unique effectsof a given model have found noof a given model have found nodifferencesdifferences——nor has recent metanor has recent meta--analyses…analyses…The Dodo VerdictThe Dodo Verdict——thethemost replicated finding in themost replicated finding in thepsychological literaturepsychological literature

“Everybody has won and all“Everybody has won and allmust have prizes.”must have prizes.”

Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy.Journal of Orthopsychiatry, 6, 412-15.Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fidepsychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215.

The Search for the Holy GrailDoesn’t Do Much for Us

The Search for the Holy GrailDoesn’t Do Much for Us

Helping is no moreeffective now with all ourtreatment technologies(400 of them) andempirically supportedtreatments (almost 150 ofthem) than 40 years ago.

So how can we becomebetter?

Helping is no moreeffective now with all ourtreatment technologies(400 of them) andempirically supportedtreatments (almost 150 ofthem) than 40 years ago.

So how can we becomebetter?


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Personal therapy andPersonal therapy andincreasing our selfincreasing our selfawareness makes us aawareness makes us abetter person andbetter person andimproves our outcomesimproves our outcomes

FalseFalseWhile therapists findWhile therapists findpersonal therapypersonal therapyinvaluable, it neitherinvaluable, it neitherhelps nor hindershelps nor hindersoutcomes.outcomes.

Geller, J.,Geller, J., NorcorssNorcorss, J.,&, J.,& OrlinkskyOrlinksky D. (2005).D. (2005). TheThepsychotherapist’s Own Psychotherapy.psychotherapist’s Own Psychotherapy. New York:New York:Oxford Univ. Press.Oxford Univ. Press.

Personal Therapy/Self AwarenessThe Royal Road to Better Outcomes?

Personal Therapy/Self AwarenessThe Royal Road to Better Outcomes?

Idea arose frompsychodynamicthinking…experience inclient’s place makessense, but, and this is avery big but, it doesn’timprove outcomes oneiota!


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ProfessionalProfessionalTraining andTraining andContinuingContinuingEducation have aEducation have adirect impact ondirect impact onoutcomesoutcomes..

FALSEFALSENo difference inNo difference inoutcomes betweenoutcomes betweendisciplines, trainingdisciplines, trainingmodels, and not onemodels, and not onestudy supports CE asstudy supports CE ashelping outcomeshelping outcomes

The Value of TrainingAnother Nail in the Coffin

The Value of TrainingAnother Nail in the Coffin

Need seems obvious, but it haslong been known thatprofessional training/disciplinematters little to outcome

2010 issue of the JCD, Nyman,Nafziger, & Smith reported thatit didn’t matter to outcome ifthe client was “seen by alicensed doctoral–levelcounselor, a pre-doctoralintern, or a practicumstudent.”

Need seems obvious, but it haslong been known thatprofessional training/disciplinematters little to outcome

2010 issue of the JCD, Nyman,Nafziger, & Smith reported thatit didn’t matter to outcome ifthe client was “seen by alicensed doctoral–levelcounselor, a pre-doctoralintern, or a practicumstudent.”


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The accruedThe accruedwisdom of clinicalwisdom of clinicalexperience, years ofexperience, years ofseasoning,seasoning,improves outcomesimproves outcomes

FALSEFALSEThe cold hard realityThe cold hard realityis that experienceis that experiencemakes no difference.makes no difference.

Experience Is the Best Teacher?Getting Better All the Time?

Experience Is the Best Teacher?Getting Better All the Time?

All of us want to think thatwe are getting better.

But are we getting betteror are we having the sameyear of experience overand over?

Less exp. therapistsachieve about the sameresults so how do we getbetter? Contrary…

All of us want to think thatwe are getting better.

But are we getting betteror are we having the sameyear of experience overand over?

Less exp. therapistsachieve about the sameresults so how do we getbetter? Contrary…


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How Therapists DevelopOrlinsky & Rønnestad

• 5000 therapists

• The Pinnacle ofDevelopment—HealingInvolvement: committed& affirming, high level ofempathic skills, consciousof “flow,” feeling effective,& dealing constructivelyw/ difficulties. How do weget there?

Orlinsky, D. E., Rønnestad, M. H. (2005).How psychotherapists develop:Washington, DC: APA.

• Improvement in skills,increasing mastery, &surpassing pastlimitations.

• 86% “highly motivated”to pursue prof. dev.

• No profession morecommitted—Therapistswant to continue to getbetter over their careers

First Source of AccelerationCumulative Career Development


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Sources of AccelerationTheoretical Breadth

Therapists at everystage who combinedseveral theoreticalperspectives were the“most growing” &more likely to exp.Healing Involvement.

Biggest Source of Development

Currently Experienced Growth

• “What have you donefor me lately?”

• Our work is a calling,so our dev. isimportant to us—somuch so that we keepa finger on the pulseof it at all times.


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How Do We AttainCurrently Experienced Growth

• Experiential learningthru clinical work

• Beyond cliché,therapists believe thatclients are the bestteachers—our primaryaccess to Growth

More Self Delusion?

• The astute participantmight be thinking: “Wait aminute, isn’t HealingInvolvement just moretherapist self-delusionsabout how effective theyare?” Yes, it would be if itweren’t for the client, andtheir feedback.


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To The RescueConsumer Driven Outcomes Management

To The RescueConsumer Driven Outcomes Management

Howard et al. (1996) advocatedfor the systematic eval. of clientresponse during treatment to“determine the appropriatenessof the current tx…the need forfurther tx…[and] prompt aclinical consultation for patientswho [were] not progressing atexpected rates”

Howard et al. (1996) advocatedfor the systematic eval. of clientresponse during treatment to“determine the appropriatenessof the current tx…the need forfurther tx…[and] prompt aclinical consultation for patientswho [were] not progressing atexpected rates”

Feedback and OutcomeLambert’s Five Trials

Feedback and OutcomeLambert’s Five Trials

All 5 sig. gains for feedback

22% of TAU at-risk casesimproved compared with 33%for feedback to therapists,39% for feedback totherapists & clients, & 45%when supplemented withsupport tools

A strong case for routinemeasurement of outcome ineveryday clinical practice

All 5 sig. gains for feedback

22% of TAU at-risk casesimproved compared with 33%for feedback to therapists,39% for feedback totherapists & clients, & 45%when supplemented withsupport tools

A strong case for routinemeasurement of outcome ineveryday clinical practice


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Feedback v TAU;Both persons reliableor sig. change—50.5% v. 22.6%;ES: .50; 4 xs # ofclin. sig. change

FU: TAU-34.2% v.18.4% Feedbacksep./divorce rate

Feedback v TAU;Both persons reliableor sig. change—50.5% v. 22.6%;ES: .50; 4 xs # ofclin. sig. change

FU: TAU-34.2% v.18.4% Feedbacksep./divorce rate

Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback toimprove couple therapy outcomes: A randomized clinical trial in anaturalistic setting. Journal of Consulting and Clinical Psychology,77(4), 693-704.

Becoming BetterIsn’t It Good, Norwegian Wood

Becoming BetterIsn’t It Good, Norwegian Wood

Barry Finds the Spot in the Norway Picture

By Coincidence


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Reese, Norsworthy, & Rowlands (2009)First Independent Study

Reese, Norsworthy, & Rowlands (2009)First Independent Study

N=148: Feedback groupdoubled controls (10.4vs. 5.1 pts); ES: .48

Like Norway study,clients, regardless of riskstatus, benefit fromcontinuous feedback

And the replication study

now in press

N=148: Feedback groupdoubled controls (10.4vs. 5.1 pts); ES: .48

Like Norway study,clients, regardless of riskstatus, benefit fromcontinuous feedback

And the replication study

now in press

Reese, R., Norsworthy, L., &Rowlands, S. (2009). Does acontinuous feedback modelimprove psychotherapyoutcomes? Psychotherapy,46,418-431.

Reese, R., Toland, M., Slone, N.,& Norsworthy, L. (in press).Effect of client feedback oncouple psychotherapyoutcomes. Psychotherapy.

Therapist Developmentand Feedback

• Client feedback monitorsoutcome & plots cumulativecareer development.

• Tailoring services leads totheoretical breadth to servemore clients.

• Securing client feedback placestherapists in acceleratedcourses of development in thefront of the class to see andhear the lessons of the day—toexperience currentlyexperienced growth.


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••Considered most sophisticatedConsidered most sophisticatedcomparative clinical trial ever:comparative clinical trial ever:

••CBT, IPT, Drug, PlaceboCBT, IPT, Drug, Placebo

Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of GeneralPsychiatry, 46, 971-82.

••NoNo differencedifference in outcomein outcome••TheThe client’sclient’s rating of the alliance atrating of the alliance atthe second session the best predictorthe second session the best predictorof outcome across conditions.of outcome across conditions.

Therapist DevelopmentFocusing on What Works: TDCRP

Therapist DevelopmentFocusing on What Works: TDCRP

Client/Extratherapeutic Factors (87%)

Treatment Effects13%

Feedback Effects15-31%

Alliance Effects38-54%

Model/Technique8%

Model/Technique Delivered:Expectancy/AllegianceRationale/Ritual (GeneralEffects)

30-?%

Therapist Effects46-69%


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On Becoming A Better TherapistBottom Line

On Becoming A Better TherapistBottom Line

Privilege clients’experience & rallytheir resources tothe cause.

Privilege clients’experience & rallytheir resources tothe cause.

“The quality ofthe patient'sparticipation . . .[emerges] asthe mostimportantdeterminant ofoutcome."

Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years ofprocess -outcome research: In M. J. Lambert (Ed.), Bergin andGarfield’s handbook of psychotherapy and behavior change (5th ed.,pp. 307-390). New York: Wiley.





Model/Technique8%


30-?%


Duncan, B. (2010). On becoming a better therapist.Washington DC: American PsychologicalAssociation


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In the TDCRP, 8% of theoverall variance in theoutcomes within eachtreatment was due totherapists…or 62% of thevariance attributed totreatmentWhat accounts for thevariability? Tune in later!



Kim, D. M., Wampold, B. E., & Bolt, D. M. (2006). Therapist effects in psychotherapy:A random effects modeling of the NIMH TDCRP data. Psychotherapy Research, 16, 161-172.





Model/Technique8%


30-?%




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The AllianceBottom LineThe Alliance

Bottom Line

The AllianceMatters—Big Time

TDCRP: allianceaccounted for upto 21% of theoverall variance…

The AllianceMatters—Big Time

TDCRP: allianceaccounted for upto 21% of theoverall variance…

But What About This Client?But What About This Client?

While the data give generalguidance, it does little to informwhat will help a particular client.

To know what is therapeutic, theclient’s view regarding both thealliance and outcome is key.

The real question: Does this clientexperience this interaction at thistime and place to be therapeutic?And the only way to do this is viaclient feedback

While the data give generalguidance, it does little to informwhat will help a particular client.

To know what is therapeutic, theclient’s view regarding both thealliance and outcome is key.

The real question: Does this clientexperience this interaction at thistime and place to be therapeutic?And the only way to do this is viaclient feedback


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Model/Technique8%


30-?%



Feedback As A Common FactorFeedback As A Common Factor

Overlaps with & affects allfactors—tie that binds

Soliciting feedback is aliving, process that engagesclients in monitoringoutcome, heightens hope,fits client preferences,maximizes therapist-clientfit, and is itself a corefeature of change.

Overlaps with & affects allfactors—tie that binds

Soliciting feedback is aliving, process that engagesclients in monitoringoutcome, heightens hope,fits client preferences,maximizes therapist-clientfit, and is itself a corefeature of change.


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Becoming BetterFeedback Is My Compass

• Not an uninhabited terrain oftechnical procedures, nor thepredictable path of diagnosis,prescription, & cure. Cannot bedescribed w/o the client &therapist, co-adventurers in ajourney across unchartedterritory. Common factorsprovide landmarks for thisinterpersonal & idiosyncratic trip,& specific models provide well-traveled directions to consider,but feedback provides thecompass, showing the way tothe desired destination.

• Pre-requisite: youare a primaryfigure—the client iscentral, but it takestwo to tango. Yourgrowth impactsyour ability to bevitally involved.

Becoming a Better TherapistAccelerate Your Development


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For the Love of the WorkOn Becoming a Better Therapist

• If you got into this business, likeme & the majority, because youwanted to help people, youalready have what it takes. Twothings: One is your commitmentto monitor the alliance and theoutcome of the services. Thesecond is your investment inyourself, your own growth anddevelopment. Client feedbackprovides the method for both,the compass for the journey.

About the Bookand the Webinars

The American Psychological

Association is the publisher

www.apa.org/pubs/books

2. Just the Facts, Ma’am’

3..How Being Bad…

4.Getting in the Zone

5. Heart and Soul of Change

6.Wizards, Humbugs, Witches

7. For the Love of the Work