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The slide package presents chapter four of On Becoming a Better Therapist, and the three sources of Orlinsky and Rønnestad’s empirically derived concept of Healing Involvement: First, tracking your cumulative career development with outcome data takes the guesswork out of your growth and ensures that you benefit from your experience over time and not merely repeat it. Regarding theoretical breadth, the second source, drop the belief in the “truth” value of any given approach in favor of adding many valid myths and rituals to your repertoire. Finally, the primary source of Healing Involvement, your currently experienced growth , keeping your finger on the pulse of your development so that you stay vital in the face of the everyday demands of the work. This presentation details a proactive process in which you systematically examine your work with your current clients, and apply a strategy of empowerment and reflection to harvest the lessons of clinical experience.

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  1. 1. 10/29/2010 1 On Becoming a Better Therapist Accelerating Your Development Barry Duncan,Barry Duncan, Psy.DPsy.D. 954.721.2981 www.whatsrighwithyou.com954.721.2981
  2. 2. 10/29/2010 2 Winter Getaway! Training of Trainers Winter Getaway! Training of Trainers  HSCP Training of Trainers (TOT): Jan. 31- Feb. 4, 2011 (24 hours of CEs) This intensive training experience gives you all you need to train others and implement CDOI. And it provides the first step in becoming an HSCP Certified Trainer of CDOI.  HSCP Training of Trainers (TOT): Jan. 31- Feb. 4, 2011 (24 hours of CEs) This intensive training experience gives you all you need to train others and implement CDOI. And it provides the first step in becoming an HSCP Certified Trainer of CDOI.
  3. 3. 10/29/2010 3 Getting in the Zone Becoming Better at What We Do • Two things: One is your commitment to monitor the alliance and the outcome of the services. The second is your investment in yourself, your own growth and development. Client feedback provides the method for both, the compass for the journey. • Feedback v TAU; Both persons reliable or sig. change—50.5% v. 22.6%; ES: .50; 4 xs # of clin. sig. change • FU: TAU-34.2% v. 18.4% Feedback sep./divorce rate Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693-704. Becoming Better Isn’t It Good, Norwegian Wood Becoming Better Isn’t It Good, Norwegian Wood
  4. 4. 10/29/2010 4 Regarding Therapist Variability Feedback Improves Outcomes Regarding Therapist Variability Feedback Improves Outcomes • Norway: 9 of 10 got better outcomes • Therapist in low effectiveness group became the BEST with feedback! Blown Away Therapist Effects and Feedback • Correlation b/w the effectiveness of a t with no feedback & feedback effect was r = -.99. Feedback acts as a “leveler,” raising effectiveness of lower or ave. ts to their more successful colleagues.
  5. 5. 10/29/2010 5 Becoming Better Accelerating Your Development • Feedback tailors therapy based on response, provides an early warning system to prevents drop- outs & negative outcomes, & solves therapist variability—feedback improves performance and quickens your development… How Therapists Develop Orlinsky & Rønnestad • 5000 therapists (11,000) • The Pinnacle of Development—Healing Involvement: committed & affirming, high level of empathic skills, conscious of “flow,” feeling effective, & dealing constructively w/ difficulties. Orlinsky, D. E., Rønnestad, M. H. (2005). How psychotherapists develop: Washington, DC: APA.
  6. 6. 10/29/2010 6 Immediately Fascinating A Unified Profession • What is immediately fascinating about this study is the consistency of results across profession, nationality, gender, and theoretical orientations. Psychotherapy, in all its variations, seems to be a unified profession, despite what our professional org. and theories tell us. • Healing Involvement Us at Our Best • Our immersion into our client’s story is so complete, our attunement so sharp, that the path required for change becomes eminently accessible. Sometimes you feel the texture of your connection with clients, an intimate space where you both know that there is something very good about this conversation. This is HI—the reason we do the work and the intrinsic reward it offers. How can we make it happen more often?
  7. 7. 10/29/2010 7 How Therapists Develop Orlinsky & Rønnestad Three Sources of Therapist Growth: • Cumulative Career Development; Theoretical Breadth, and the most important, Currently Experienced Growth • Pre-requisite: you are a primary figure—the client is central, but it takes two to tango. Your growth impacts your ability to be vitally involved. Becoming a Better Therapist Accelerate Your Development
  8. 8. 10/29/2010 8 First Source of Acceleration Cumulative Career Development First Source of Acceleration Cumulative Career Development • Improvement in skills, increasing mastery, & surpassing past limitations. • 86% “highly motivated” to pursue prof. dev. • Therapists continually evaluate where they are versus where they started A Distinctive Narrative • No profession more committed—therapists want to continue to get better over their careers • Orlinsky & Rønnestad: Our development is just as important to us at end of our careers as it is in the beginning.
  9. 9. 10/29/2010 9 Cumulative Career Development Getting Better All the Time? • All of us want to think that we are getting better. • But are we getting better or are we having the same year of experience over and over? • How do we know if we are getting better or deluding ourselves? Do We Really Know? • Dew & Reimers had therapist grade their effectiveness, A+ to F— 67% said A or better; none rated below average. •• ProvidersProviders don’t knowdon’t know how effective they arehow effective they areSapyta, J., Riemer, M., & Bickman, L. Feedback to clinicians: Theory, research, and practice. Journal of Clinical Psychology: In Session, 61, 145-153
  10. 10. 10/29/2010 10 Measuring Outcomes Removes Ambiguity • Allows you to use the evidence about therapist growth without falling prey to pitfalls of a therapist-centric view of success. • Cumulative Development Tracking Doesn’t have to be Complicated Start by entering data into Excel, & tracking outcome with simple calculations: ave. intake & final session scores, ave. change score, the % of clients who reach reliable or clinically significant change, & “drop outs.”
  11. 11. 10/29/2010 11 Client benefit a better way. Trying to avoid client who discontinues in an unplanned way, w/o experiencing target. If it's planned, then we have referred the client on to greener pastures. If it is unplanned but the client reached target, then that is okay too. A Brief Word About Drop OutA Brief Word About Drop Out Onus and Blame on ClientOnus and Blame on Client A Brief Word About Drop OutA Brief Word About Drop Out Onus and Blame on ClientOnus and Blame on Client •Clinically significant change is 5 or more points on the ORS plus crossing the clinical cutoff or 25 •Reliable change is a change of 5 or more: more than attributable to chance, measuremen t error or maturation Reliable or Clinically Significant Change Reliable or Clinically Significant Change
  12. 12. 10/29/2010 12 Cumulative Career Development ASIST and • The single bit of information that tells you the most is the % who reach target— the 50th percentile trajectory for clients entering services with the same intake score. Reviewing Graphs First Things First
  13. 13. 10/29/2010 13 Becoming Better Consider Benefits of Tracking Outcome • Allows a systematic trial and error application of new learning as well as the refinement of the tried and true mechanisms that we know enhance outcomes. • Tracking cumulative career development enables reflection and action about effectiveness. Cumulative Career Development Start with the Common Factors • Models/techniques, but… • Focus on the common factors. • Practice well the skills of the craft—the alliance. At some point, craft becomes art. Relational repertoire likely parallels your development
  14. 14. 10/29/2010 14 Client/Extratherapeutic Factors (87%) Treatment Effects 13% Feedback Effects 15-31% Alliance Effects 38-54% Model/Technique 8% Model/Technique Delivered: Expectancy/Allegiance Rationale/Ritual (General Effects) 30-?% Therapist Effects 46-69% Duncan, B. (2010). On becoming a better therapist. Washington DC: American PsychologicalAssociation Client is the of Change • Client’s Resources, Resiliencies, and Relational Support • Client’s View of the Alliance • Client’s View of Progress &Expectation of Success
  15. 15. 10/29/2010 15 Alliance As An Overarching Framework The Alliance is the Soul • Transcends any beh & is a property of all—from tech. to scheduling an appt • Purpose is to engage in purposive work • Have to earn it each & every time; alliance is our craft; practice elevates to art Becoming Better Take Charge • Track effectiveness by quarter or 30 client block. • Keeps your dev. front & center; implement ideas, practices, & models, as well as building skills. • Will readily see whether efforts are paying off, if your chosen methods of increasing effectiveness need to be tweaked or changed outright.
  16. 16. 10/29/2010 16 Sources of Acceleration Step 2. Theoretical Breadth Therapists at every stage who combined several theoretical perspectives were the “most growing” & more likely to exp. Healing Involvement. Becoming Better at What We Do Expand Your Theoretical Breadth Becoming Better at What We Do Expand Your Theoretical Breadth • Loosen your grip on the “truth” of any approach • Theoretical loyalty brings certainty (certain failure); theoretical promiscuity brings uncertainty (but fits more clients)
  17. 17. 10/29/2010 17 Theoretical Breadth We All Have Pet Theories • We all have those that seem to fit with who we are, that match our ideas of how people can change • But all approaches have validity, all are but metaphorical accounts of how people can change. • It is the fit that matters, & whether any approach resonates with both the client and the therapist. Believing in the Truth Not Rocket Science • Can hold only 3/4 systems • But far more frames or structures or explanations. • Open up to Franks observation that the important stuff is that models offer a rationale and a ritual. • They don’t require 2 yrs of supervision to understand or implement, but keep that under your hat.
  18. 18. 10/29/2010 18 Becoming Better Theoretical Breadth • Stepping outside comfort zones make us vulnerable—cookie cutter therapy is much easier to do, but we don’t grow much. • Let go a bit, like singing in the shower or dancing when no one is looking. How Do You Broaden Theoretical Horizons? • Start with those that fit your views of human nature, problems, and solutions, & their relatives. • Set self conscientiousness to the side—let the client’s theory be your theory with that client…Claire • Be proactive. Play “on other hand” games
  19. 19. 10/29/2010 19 Plurality Pays Off Differential Efficacy with Current Client • Q: Does it resonate; does it fit client preferences; can both get behind it? • Alliance skills: explore client ideas, discuss options, collaboratively plan, and negotiate changes if benefit not forthcoming. • Alliance in action. Litmus test: whether it engages client in purposive work. Biggest Source of Development 3. Currently Experienced Growth • “What have you done for me lately?” • Our work is a calling, so our dev. is important to us—so much so that we keep a finger on the pulse of it at all times.
  20. 20. 10/29/2010 20 Perhaps the Most Significant Finding The perception of getting better over time and a palpable experience of current growth enliven therapy and staves off burnout. Currently Experienced Growth and Morale • Closely associated with work morale. Energizes therapists to apply their skills & understandings • Remoralizes, repairs abrasions & stressors of the work. • Combats routinization, disillusionment, & loss of empathy.
  21. 21. 10/29/2010 21 Growth is our Primary Way to Fend of Disenchantment • “CEG the balm that keeps our psychological skin permeable—many commonly believe that the constant hearing of problems would lead one to be emotionally callused and develop a ‘thick skin.’ But not for therapists—we need ‘thin skin,’— open, sensitive, and responsive to contact with clients.” Currently Experienced Growth Both the reward for doing our work and our greatest ally for sending the grim reaper of burnout packing.
  22. 22. 10/29/2010 22 How Do We Attain Currently Experienced Growth • Experiential learning thru clinical work • Beyond cliché, helpers believe that clients are the best teachers— our primary access to Growth Beyond Cliché • . Impossible to routinely sit with people in the throes of disaster, then witness their journey to a better place, and not be changed. Lean about the human condition, different cultures and world views, as well as the myriad of ways that people transcend adversity and cope with the unthinkable. While noteworthy, tracking outcome takes the notion that “the client is the best teacher” to a different and perhaps more practical level.
  23. 23. 10/29/2010 23 Attention to the Here and Now Clients teach us with their responses—whether they are benefiting & whether our service is a good fit—as well as their reactions & reflections re the next step. Clients who are not benefiting offer us the best opportunity for learning, helping us step outside our comfort zones. Proactively Consider the Lessons and Reflect • Any difference can be an important marker that highlights your currently experienced growth. Perhaps you did something for the first time with a client, or a light went on and you now understand something in a different way.
  24. 24. 10/29/2010 24 Making the Best of Currently Experienced Growth • Review current clients, consider lessons. • Empower yourself, like your clients, to enable the lessons to take hold. • Articulate how client lessons have changed your work, your identity & how you describe what you do…Ann Learning from Clients Our Norwegian Colleague • I became more transparent, more courageous. I felt more secure and conveyed it. • Clients and I got more concrete about change, how it started, and what else would be helpful. • Feedback sharpened my focus—pinpointed that we have a common purpose.
  25. 25. 10/29/2010 25 Our Norwegian Colleague (cont) Be Proactive • Feedback helped me take risks and invite negative comments. • Made me more secure, I am far more daring. I am now more collaborative and allow things to emerge rather than following a set way to work. Study Says Something Important About Who and What • Tracking outcomes enables big picture view of CCD, and a microscopic view of CEG. • Both perspectives allow you to continually reflect about your development and test your assumptions, adjust to client preferences, master new tools & learn new ideas
  26. 26. 10/29/2010 26 Getting Better Is Part of Your Identity • But you have to keep your head and heart in the game in spite of all the reasons that conspire —like funder mandates, unrealistic productivity requirements, meaningless paperwork, and gut-wrenching client circumstances to —for you to accept monotony and negative outcomes. Ensuring Development with Outcome Feedback • Client feedback monitors outcome & plots cumulative career development. • Tailoring services leads to theoretical breadth to serve more clients. • Securing client feedback places providers in accelerated courses of development, in the front of the class to see and hear the lessons of the day—to experience currently experienced growth.