Barryshandouts

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640 C lie n t/E x tr a th e ra p e u tic 4 0 .0 % R e la tio n s h ip M o d e l/T e c h n iq u e s 3 0 .0 % 1 5 .0 % 1 5 .0 % P la c e b o , H o p e , a n d E x p e c ta n c y Michael Lambert’s Pie Chart of the Common Factors Client Factors: Accounting for 40% of Change Research makes clear that the client is actually the most potent contributor to successful outcome—the resources clients bring into your agency and what influences their lives outside it. These factors might include persistence, openness, faith, optimism, a supportive grandmother, or membership in a religious community: all factors already in a client's life before he or she arrives at your doorstep. They also include serendipitous interactions between such inner strengths and happenstance, such as a new job or a crisis successfully negotiated. Relationship Factors: Accounting for 30% of Change Next to what clients bring, their perceptions of the relationship with you are responsible for most of the gains resulting from any helping endeavor. Now usually called the "alliance," it is most easily understood as a partnership between the client and helper predicated on a strong agreement on the goals and tasks of therapy. Client's favorable ratings of the alliance are the best predictors of success—more predictive than diagnosis, approach, therapist, or anything else.

2 Expectancy/Placebo: Accounting for 15% of Change Expectancy refers to the portion of improvement deriving from clients' knowledge of being helped, the instillation of hope, and how credible the client perceives your rationale and techniques. These effects do not come specifically from a given treatment procedure; they come from the hopeful expectations that accompany the method. Model/Technique Factors: Accounting for 15% of Change Model/technique factors are the beliefs and procedures unique to specific treatments like the miracle question in solution-focused therapy or challenging generalizations in cognitive- behavioral therapy or confrontation in twelve-step work. Despite all the hoopla around the power of models, it is worthy to note that not one has demonstrated any superiority over any other—this is the so-called “dodo bird verdict” (“All have won and all must have prizes” from Alice in Wonderland), first coined by Saul Rosenzweig. The verdict colorfully summarizes that approaches work about the same and points to elements common across models that better explain successful outcomes—namely the innate resources of the client, the quality of the relationship, and the hope for a better future. How exactly should models be viewed when so much of good clinical work is controlled by other factors—85% to be exact (40% client factors, 30% relationship factors, and 15% expectancy factors)? Read on. Empowering Client Factors 1. Develop a change-focus.  Listen for a change--whenever and for whatever reason it occurs. Ask about what, if any, changes clients have noticed since the time they scheduled their appointment. (monitor and measure change) Many people notice that, between the time they called for the appointment and the actual first session, things already seem different. What have you noticed about your situation?  Listen for key words that reflect change. When clients say: Thing have been really bad until recently; He is failing all of his classes except math. Take notice and follow up. 2

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640  Ask about change between sessions. What is different since our last meeting? What is better? TIPS 2. Listen for heroic stories. Consider these questions for clients:  The key here is the 1. What are the traits, qualities, and characteristics that attitude you assume describe you when you are at your very best? What were you regarding your doing when these aspects became apparent to you? client’s inherent 2. What kind of person do these aspects describe? abilities—you must 3. What are the traits, qualities, and characteristics that others foster a determined would describe in you when you are at your very best? What mindfulness to find were you doing when they noticed these aspects in you? competencies, 4. What kind of person do these aspects describe? strengths, resiliencies, 5. Who was the first person to tell you that they noticed the best and resources that of you in action? What were you doing when they noticed you know are there. these aspects? 6. Who was the last person to tell you that they noticed the best  This does not mean of you in action? What were you doing when they noticed that you must ignore these aspects? pain or assume a 7. Who in your life wouldn’t be surprised to see you stand up to Pollyanna stance. these situations and prevail? What experiences of you would Rather, it only they draw upon to make this conclusion?? requires that you give voice to the whole 8. When I am at my very best, I am story: the confusion ______________________________________. and the clarity; the Consider these questions for therapists: suffering and the  What are the obvious and hidden strengths, resources, endurance; the pain resiliencies, and competences contained in the client’s story? and the coping; the  What are the competing stories that can be told—the stories of clarity, coping, endurance, and desire that exist simultaneously with the stories of confusion, pain, suffering, and desperation?  What is already there to be recruited for change?

4 desperation and the desire.  The stories of who we are have multiple sides, depending on who is recounting them and what sides are emphasized. Unfortunately, the Killer Ds (diagnosis, dysfunction, disorder, disease, deficit) have persuaded us to believe in the story of pathology as the only or best version. It is neither. Many others of survival and courage simultaneously exist—help your clients tell stories that portray their courage and heroism. 3. Validate the client's contribution to change.  When change happens, ask clients to elaborate the change and their contribution to it. What was happening at those times? What do you think you were doing to help that along? What would you need to do (or what would need to happen) to experience more of that? As you continue to do these good things TIPS for yourself (or take advantage of what Telling Heroic Stories: is helping), what difference will that make tomorrow? How will your day go  Think of a time in your life that was very better? The day after? difficult, but you managed to get through it.  What personal resources did you draw on  Link the positive change to the client’s to get through this difficulty? own behavior. Even if clients attribute  What family, spiritual, friend, or community support did you draw on to get change to luck, fate, you, or a through? medication they can still be asked: (1)  What does this story tell about who you are and what you can do? how they adopted the change in their  Who else knows this story about you? lives, (2) what they did to use the  What do you think they say this story says changes to their benefit, and (3) what about who you are and what you are capable of? they will do in the future to ensure their gains remain in place. Wait a second. You did what? Tell me more. How did you know to do what you did? That was thoughtful. What is it about you that helped you to do what you did? What does it say about you that you took advantage of the medication at this time? What part of you was lying dormant, ready to come out that the medication gave a boost to? 4. Tap into the client’s world. Whether seeking out a trusted friend or family member, purchasing a book or tape, attending church or a mutual-help group, clients find support outside of your agency.  Listen for and then be curious about what happens in the client's life that is helpful. 4

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640  Inquire about the helpful aspects of the client's social support network, activities that provide relief, even if temporary, and circumstances in which the client feels most capable, successful, and composed. TIPS  Identify not what clients need, Validation requires you to accept your client at face value and but what they already have in search for justification of his or her experience—replacing the their world that can be put to invalidation that may be a part of it. Ask yourself the following use in reaching their goals questions about the client’s story: Whom does the client refer to • What are the obvious and hidden invalidations contained in as helpful in his or her day-to- the client’s story? How is the client or others discounting or day life? How or what does the client contradicting his or her experiences? How is he or she or do to get these persons to help others blaming the client for this situation? him or her? What persons, places, or • What other factors or circumstances have contributed to things does the client seek out this situation or are extenuating or mitigating variables? between sessions for even a small measure of comfort or How can I place the client’s situation in a context that aid? explains and justifies his or her behavior or feelings? How What persons, places, or things has the client sought can I give the client credit for trying to do the right thing? out in the past that were • How is this experience representative of an important useful? What was different about crossroad in the client’s life or a statement about his or her those times that enabled the identity? What message is the client’s internal wisdom client to use those resources? attempting to express? Empowering Alliance • Put the client’s experience in the following format: No wonder you feel or behave this way (fill in with client Factors circumstance) given that (fill in the ways you have discovered to 1. Court the client's favor and woo justify his or her responses). their participation—fit their ideas Finally: of a good relationship • Now that the client is validated, what different conclusions  Carefully monitor the client’s are reached? Did any other courses of action emerge? reaction to comments,

6 explanations, interpretations, questions and suggestions. Use the client’s language—their words, ideas, and expressions. Stay close to their descriptions of their lives. (Monitor and measure the alliance.)  Be flexible. Some clients will prefer a formal or professional manner over a casual or warmer one. Others might prefer more self-disclosure from their therapist, greater directiveness, a focus on their symptoms or a focus on the possible meanings beneath them, a faster or perhaps, a more laid back pace for therapeutic work. The one-approach- fits-all strategy is guaranteed to undermine alliance formation. You are multidimensional—you are already many things to many people (friend, partner, parent, child, sibling). Use your complexity to fit clients! (Monitor and measure the alliance.)  Validate the client. Validation occurs when client’s thoughts, feelings, and behaviors are accepted, believed, and considered completely understandable given trying circumstances. Legitimize the client’s concerns and highlight the importance of the client’s struggle. 2. Accept client goals at face value.  Work on client goals, period.  Listen and then amplify the stories and experiences that clients offer about their problems, including their thoughts, feelings, and ideas about “where they want to go and the best way to get there.” (Monitor and measure the alliance.)  Ask directly about the client’s goals. What is your goal for treatment? What did you (hope/wish/think) would be different because of coming here? What did you want to change about your (life/problem/etc.)? What would have to be minimally different to consider our work together a success? What will be the first sign to you that you have taken a solid step on the road to improvement even though you might not yet be out of the woods? 3. Form all plans and tasks with the client. Fit the client’s theory of change (see below) (Monitor and measure the alliance.)  Change is done with rather than to the client (e.g., fill out a genogram, take this medication, go into trance).  In a good alliance, helpers and clients jointly work to construct interventions that are in accordance with clients’ preferred outcomes. In this light, interventions represent an instance of the alliance in action. They cannot be separated from the client’s goals or the relationship in which they occur. 6

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640 Empowering Expectancy Factors 1. Believe in the client, in yourself and your work, and in the probability of change.  Show your faith in the client and your trust in your services. Know that no matter how troubling the client’s situation is, that it will change.  Show interest in the results of whatever technique you employ. Ask about the beneficial effects of the therapy at some point during each session. Ask clients to notice and record any changes for the better that occur between sessions. Convey hope for and expectation of improvement. 2. Orient therapy toward a hopeful future. Clients are best served by helping them believe in possibilities—of change, of accomplishing or getting what they want, of starting over, of succeeding or controlling their life.  Facilitate hope and positive expectations for change by exploring the pessimistic assumptions clients have TIPS about the future. Ask Choose an approach by asking yourself these questions: questions to assist clients in  Does the particular strategy capitalize on client strengths, envisioning a better future: resources, and abilities? What will be different when (anxiety, drinking, feuding  Does the orientation/intervention use the client’s existing with others, etc.) is behind support network? you? What will be the smallest sign  Does the method identify or build on the changes clients that it’s getting better? What experience while in therapy? will be the first sign? When you no longer spend so  Would the client describe the therapeutic interaction resulting much time struggling with from the adoption of the particular strategy or orientation as (______), what will you be doing more of or instead? empathic, respectful, and genuine? Who will be the first person to  Does the orientation/technique identify, fit with, or build on the notice that you have achieved a victory? client’s goals for therapy? What will that person notice  Does the orientation or strategy fit with, support, or different that will tell him or complement the client’s world view and theory of change?  Does the theory or intervention fit with the client’s expectations for therapy?

8 her that the victory is achieved? Where do suppose you will be when you first noticed the changes? What will have taken place just before the changes that will have helped them to happen? What will happen later that will help maintain them? 3. Highlight the client’s sense of personal control.  People who believe they can influence or modify the course of life events cope better and adjust more successfully. Ask questions that presuppose client influence over events occurring in his/her life. It is impressive that you took that step on your own to let the depression know who’s boss. When did it occur to you that that was the right thing to do? Now that you have done this, what else will you do to keep the depression on a short leash?  Connect with or draw upon a previously successful experience of the client. This shines a spotlight on the client’s agency and enhances hope for a different future. Have you ever faced anything like this before? What happened? How did you do that? What were the steps you went through? Who did you involve? Can you do any of those things now? Empowering Model Factors 1. Use models to provide structure and focus.  One of the best predictors of negative outcome is a lack of focus and structure.  Find a structure that fits the client’s goals and preferences. All models, although the talk differs, prepare clients to take some action to help them do something different, whether developing new understandings, feeling emotion, facing fears, taking risks, or altering old patterns of behavior.  View techniques as something akin to a magnifying glass. They bring together, focus and concentrate the forces of change, narrow them to a point in place and time, and cause them to ignite into action. 2. Use a model to change your mind, not make up your mind, about a client  Models and techniques provide alternative ways of thinking and acting when change isn’t happening—they provide novelty. With over 400 models and techniques to choose from, little reason exists for continued allegiance to one when it fails. Instead, another model or technique can be considered. 8

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640  Do something different when you fail to hear reports of progress within a few hours rather than months of therapy. Change your mind earlier rather than later. The most frequent improvement occurs early with a course of diminishing returns thereafter. 3. Use technique as a vehicle for enhancing the effects of the other common factors.  Use the common factors to choose alternatives. Orientations that help you adopt a different way to identify or approach clients’ goals, establish a better match with clients’ ideas, foster hope, capitalize on clients’ strengths, and utilize environmental supports are likely to prove the most beneficial. How to Learn the Client’s Theory of Change  Make direct inquiries about the client’s goals and ideas about change: What did you (hope/wish/think) would be different as a result of coming here? What did you want to change about your TIPS (life/problem/etc.)? What would be minimally different in your life to  The client’s theory of change consider our work together a success? unfolds from a conversation What do you think would be helpful? What ideas do you have about what needs to structured by your curiosity about happen for improvement to occur? the client’s ideas, attitudes, and Many times people have a pretty good hunch about not only what is causing a problem, but speculations about change. also what will resolve it. Do you have a theory  Honoring the client’s theory occurs of how change is going to happen here? when you follow, encourage, and  Listen for or inquire about the client’s usual implement the client’s ideas for method of, or experience with, change: change or when you select a How does change usually happen? technique or procedure that fits What causes change to occur? clients’ beliefs about their What does the client do to initiate change? What do others do to initiate/facilitate change? problem(s) and the change process. What is the usual order of the change process?  As the client’s theory evolves, What events usually precede/occur during/follow after the change? implement the client’s identified solutions or seek an approach that both fits the client’s theory and provides possibilities for change.

10  Discuss prior solutions as a way of learning the client’s theory of change: What have you tried to help the problem/situation so far? Did it help? How did it help? Why didn’t it help? Exploring solution attempts enables you to hear the client’s evaluation of previous attempts and their fit with what the client believes to be helpful. Inquiring about prior solutions, therefore, allows you to hear the client’s frank appraisal of how change can occur.  Find out what your role is in the change process: How does the client view your part in the change process? Clients want different things. Some want a sounding board, some want a confidant, some want to brainstorm and problem solve, some want advice, some want an expert to tell them what to do. Explore the client’s preferences about your role by asking: How do you see me fitting into what you would like to see happen? How can I be of most help to you now? What role do you see me playing in your endeavor to change this situation? Let me make sure I am getting this right. Are you looking for suggestions from me about that situation? The Evolution of the Common Factors Now that you have a handle on the common factors, let’s look at a more complex, but satisfying representation of their effects and relationship to each other based on meta-analytic research. Remember the old public service message that showed an egg and said, “This is your brain,” and then as the egg is broken and starts to fry, the voiceover says, “This is your brain on drugs.” Think of the following figure as the common factors on drugs, or Barry on hallucinogens thinking about the factors (just kidding). Take a look at the common factors as I describe them in my new book, On Becoming a Better Therapist. 10

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640 Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) Duncan, B. (2010). On Becoming a 30-?% Better Therapist. Washington DC: APA. The pie chart view of the common factors incorrectly implies that the proportion of outcome attributable to each was static and could be added up to 100% of therapy effects. This suggested that the factors were discrete elements and could be distilled into a treatment model, techniques created, and then administered or “done” to the client. Any such formulaic application across clients, however, merely leads to the creation of another model. Another related problem is that despite descriptions of the factors as acting in concert with one another, the “pie chart” illustration promotes them as independent entities. In truth, they are interdependent, fluid, dynamic, and dependent on who the players are and what their interactions are like. So take a look at my LSD depiction of the factors above. The proportion of outcome attributable to treatment is represented with pale blue, and nested within client factors (yellow). Even a casual inspection shows the disproportionate influence this group exerts. Subtracting treatment effects— the proportion of variability attributable to therapy (13%)—from everything (mostly the client) that contributes to a therapeutic outcome (100%), 87% of results lie outside of treatment. If we blow up that 13%, the result is second circle above, the overlapping elements that comprise the 13% of variance attributable to treatment. To exemplify the various factors and their attending

12 portions of the variance, the Treatment of Depression Collaborative Research Program (TDCRP) will be enlisted. The TDCRP randomly assigned 250 depressed participants to four different conditions: CBT, interpersonal therapy (IPT), antidepressants plus clinical management (IMI), and a pill placebo plus clinical management. The four conditions—including placebo—achieved similar results, although both IPT and IMI surpassed placebo on the recovery criterion. Therapist Effects. Therapist factors represent the amount of variance attributable not to the model wielded, but rather to whom the therapist is. Depending on the study, therapist effects range from 6-9% of the overall variance of change or 46-69% of the variance attributed to treatment. In the TDCRP, 8% of the variance in the outcomes within each treatment was due to therapists. Consider also that the clients of the top third most effective psychiatrists receiving sugar pills did better than the clients of the bottom third taking antidepressants. Recent studies have found that therapists who generally form better alliances also had better outcomes. Such findings suggest that the alliance may represent the best arena for influencing the therapist effects. The Alliance. The amount of variance attributed to the alliance ranges from 5% to 7% (yellow) or 38-54% of that attributed to treatment (pale blue). In the TDCRP, the alliance was predictive of success for all conditions. Mean alliance scores accounted for up to 21% of the variance, while treatment differences accounted for at 0% of outcome variance. Keep in mind that treatment accounts for, on average, 13% of the variance. The alliance in the TDCRP accounted for more of the variance by itself, illustrating how the percentages are not fixed and depend on the particular context of client, therapist, alliance, and treatment model. Model/Technique in Context: Allegiance and Placebo (Expectancy) Factors Models achieve their effects, in large part, if not completely through the activation of placebo, hope, and expectancy, combined with the therapist belief in (allegiance to) the treatment administered. In fact, when a placebo or technically “inert” condition is offered in a manner that fosters positive expectations for improvement, it reliably produces effects almost as large as a bona fide treatment. Model/technique factors are the beliefs and procedures unique to specific treatments. As Jerome Frank seminally noted, they all include a rationale, offer a novel explanation for the client’s difficulties, and establish strategies to follow for resolving them. All models can be understood as healing rituals—technically inert, but nonetheless powerful, organized methods for enhancing the effects of client expectations for change. It pays, therefore, to have several rationales and remedies at your disposal that you believe in. The TDCRP is again 12

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640 instructive. While model accounted for negligible variance, placebo factors loomed large. On the Beck Depression Inventory, the placebo plus clinical management condition accounted for nearly 93% of the average response to the active treatment conditions. Feedback. The measurement of change, from the client’s perspective, has catapulted to the forefront of research and practice—and for good reason: monitoring client-based outcome, when combined with feedback to the clinician, significantly increases effectiveness. Our recent study in Norway found that feedback substantially increased positive outcomes. Feedback clients reached clinically significant change nearly four times more than non-feedback couples. The feedback condition maintained its advantage at 6 month follow-up and achieved nearly a 50% less separation/divorce rate. Based on a growing body of compelling empirical findings, feedback seems to improve outcomes across client populations and professional discipline, regardless of the model practiced—feedback is a vehicle to modify any delivered treatment for client benefit. Given its apparent broad applicability and lack of theoretical baggage, feedback can be argued to be a factor that demonstrably contributes to outcome regardless of the theoretical predilection of the clinician. It therefore could be considered a common factor of change. An inspection of the above figure reveals feedback to overlap with and affect all the factors—it is the tie that binds them together—allowing the other common factors to be delivered one client at a time. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitoring of outcome, heightens hope for improvement, fits client preferences, maximizes therapist-client fit, and is itself a core feature of therapeutic change. Common factors research provides clues and general guidance for enhancing those elements shown to be most influential in positive outcomes. The specifics, however, can only be derived from the client’s response to any treatment delivered—the client’s feedback regarding progress in therapy and the quality of the alliance. Feedback enables a reliable and valid method of tailoring services to the individual; therapists need not know what approach should be used with each disorder, but rather whether the delivered approach is a good fit for and benefiting the client in- the moment. As such, feedback assumes a role alongside the more widely researched client, therapist, and alliance variables, emerging as a potential common factor.

14 Why Partner with Clients? The Good, the Bad, and the Ugly of Outcome Management—and the REAL GOOD The Good: Change early on in therapy is a good predictor of eventual outcome. Yes it’s true, if you can’t get anything going by session 3, and for sure by session 6, then it is very likely at session 20, that nothing will still be happening—if the client is still around. Partnering with clients to make therapy accountable monitors the client’s view of progress to capitalize on this fact. The client’s view of the relationship is a good predictor of outcome. In fact, the client’s rating of alliance in the second session is the best predictor of success going. So if the client doesn’t like you or what’s happening early on, then don’t look for much change, except of course if you call dropping out an indication of change! Partnering with clients to make therapy accountable monitors the client’s view of the process of therapy to capitalize on this fact. The Bad: About 10% of clients account for 60-70% of mental health care expenditures. We are spending all our money on situations that are not changing. Go figure! Partnering with clients to make therapy accountable turns this situation around, opening options for both clients and therapists by providing immediate feedback when things are stuck. And the Ugly: Therapists who are not getting positive results often believe that their therapy is effective. Yes, it’s sad but true. Research shows that the helper is the last to know. Partnering with clients to make therapy accountable lets us know when, and often why, we are not effective. This information need not be painful, but rather is liberating in terms of helping us do better work. Enlisting the client makes being a helper much easier. And the REAL GOOD: Real time feedback about the outcome of services can up to double effectiveness. Research of real world outpatient settings has shown that on average, only a paltry 35% of clients improve or recover. Therapists range from about 20 to 70% in effectiveness. However, when therapists are given reliable feedback about whether or not clients are reporting benefit, effectiveness rates 14

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640 increase dramatically. No one is effective with everyone—even the best among us are not successful with almost a third of our clients. Finding this out early rather than late prevents ongoing ineffective work and encourages better options for the client. Our research showed that real time feedback doubled therapist effectiveness! Other studies show up to a 65% increase in effectiveness. Outcome management offers an alternative to burdensome and meaningless paperwork. For years, counselors have endured heavier and heavier burdens of paperwork. Now there is an alternative. Imagine this: Partnering with clients to monitor process and outcome on just two brief forms is the only paperwork required—that’s right, no more diagnostic workups, treatment plans, intake forms, or any other form or practice that doesn’t have any relevance to outcome. You say I’m a dreamer, but I’m not the only one! It’s already happening in some places. Partnering with clients to make services accountable is already, and will continue, changing the way that mental health services are delivered. Start now! Becoming Outcome Informed In the first contact, you want to: 1. Convey commitment toward improving client’s situation 2. Convey commitment to the highest quality of care 3. Begin partnering process Ex. We are very concerned about whether you reach your goals at our agency. For this reason, it is very important that you are involved in monitoring our progress. We will make all the decisions regarding your situation together. I monitor my effectiveness with every client through the use of brief forms. These take only a couple minutes to fill out but yield a great deal of information about how things are going. I will give you one in the beginning of the session and one toward the end. This will allow us to monitor your change and my effectiveness throughout the course of our work together. I will explain this in greater detail when you arrive for your first session. If you would, please arrive 15 minutes early for your first session. This will give us time to fill out our intake forms without using any of our session time. Shall we schedule your appointment? Great!

16 Initial Session: Step 1: Introducing the ORS Ex. During the course of our work together, we will be giving you very short forms asking you how you think things are going and whether you think things are on track. We believe that to make the most of our time together and get the best outcome, it is important to make sure we are on the same page with one another about how you are doing, how we are doing, and where we are going. We will be using your answers to keep us on track. Will that be okay with you? Ex. Before we start I will greatly appreciate it if you would fill out the following form for me. The lines on this form measure the extent to which different life challenges may be impacting you at this time. Your answers would help me get a picture of the struggles that you may be facing at this time. While filling out this form keep in mind the events that have occurred in your life within the last week to the present time and the experiences you have had during that time. Ex. I’d like to introduce you to something I like to do when working with clients. This is called the ORS. Did our intake person mention it to you? Good! Let me just take a moment to provide you with a little more information about it. The ORS is an outcome measure that allows me to track where you’re at, how you’re doing, how things are changing or if they are not. It allows us to determine whether I am being helpful. That is very important to me. In a way this is monitoring both of us. I use this because I want to ensure that I am providing you with the best services possible. It only takes a minute to fill out and most clients find it to be very helpful. Would you like to give it a try? Great! Step 2: Incorporating the ORS The idea here is simple. The ORS provides an anchor of where the client is and allows a comparison point for later meetings. It involves the client in a joint effort to observe progress toward goals. Ex. From your ORS, it looks like you’re experiencing some real problems, or, From your scores, it looks like you’re feeling okay; what brings you here today? Or, if you like numbers more, Your total score is 15—wow, that’s pretty low. A score of 24 or lower indicates people who are in enough distress to seek help. Things must be pretty tough for you. Ex. The way this ORS works is that marks toward the left indicate that things are hard for you now or you are hurting enough to bring you to therapy. Your score indicates that you are really having a hard time. Would you like to tell me about it? Or if all the marks 16

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640 are to the right, Generally ,when most people make their marks so far to the right, it is an indication that things are going well for them. It would be really helpful for me to get an understanding of what it is that brought you to therapy at this point in time? Ex. And/or at some point in the meeting, you pick up on the client’s comments and connect them to the ORS: Oh, okay, sounds like dealing with the loss of your brother is an important part of what we are doing here. Is the distress from that situation account for your mark here on the ORS? Okay, so what do you think will need to happen for that mark to move toward the right? Your interest in the client’s desired outcome speaks volumes to the client about your commitment to them and the quality of service they receive. Step 3: Introducing the SRS Ex. During the session, we will take a short break in which I will give you another form that gives your opinion of our work together and if I am meeting your expectations. This information helps me stay on track. The ultimate purpose of using these forms is to make every possible effort to make coming to see me a beneficial experience for you. I need your help in making sure that I stay on the same page with you. Would that be okay with you? Ex. Before we wrap up tonight I would like you to fill out another short questionnaire. This one deals directly with how I am doing. It is very important to me that I am meeting your needs. A lot of research has shown that how well we work together directly relates to how well things go. If you could take a moment to fill it out, I will discuss it with you before you leave. Great, thanks Step 4: Incorporating the SRS At the end of the session during the final message or summary process, incorporate the SRS responses. The SRS is easily scored by measuring the client’s marks on the line in a similar fashion as the ORS. Each line is 10 centimeters long. Just pick up on an item or two on the SRS and make comment on it. If there are any scores lower than 9 centimeters, follow up on it. Generally speaking, a total score of 36 or less should be discussed. The best thing that the SRS can do for you is to allow you to fix any alliance problems that are developing. The SRS shows

18 clients that you do more than talk the talk—you are REALLY interested in their feedback and want to know what they think. Ex. Let me just take a second here to look at this SRS—it kind of like a thermometer that takes the temperature of our meeting here today. Wow, great, it looks good, looks like we are on the same page, that we are talking about what you think is important and you believe today’s meeting was right for you. Ex. Let me quickly look at this other form here that let’s me know how you think we are doing. Okay, seems like I am missing the boat here. Was there something else I should have asked you about or should have done to make this meeting work better for you? What was missing here? Just bringing up any problems and your willingness to be flexible and nondefensive speaks reams to the client and usually turns things around quickly. This process is repeated in every session. Follow up Sessions: Checking for Change Okay, you got the idea. Now it gets interesting. Here is where you get down to the business of being outcome-informed—the client’s view of progress really influences what you do.  Greet clients and provide them with the ORS to complete. You may also have a folder with blank forms available in your waiting room.  Compare this session’s ORS with the previous one and look for any changes.  Is there an improvement (a move to the right), a slide (a move to the left), or no change of any kind? Is there an increase in the total score of at least 5, or an increase to a total of 25 or more? Is there a decrease or no change at all?  Present the change or absence of change and engage the client in a discussion about their marks or scores. Ex. Holy cow! Wow, your mark on the personal well-being line really moved—about 3 centimeters to the right! What happened? How did you pull that off?…This kind of change is called a reliable change and may mean that it’s time for us to reevaluate. Where do you think we should go from here? Or, Look, your total increased by 8 points to 29 points. That’s quite a jump! Refer above to eliciting change talk about asking questions about the noted changes. Ex. Okay, so things haven’t changed since the last time we talked. How do you make sense of that? Should we be doing something different here or should we continue on course steady as we go? 18

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640 Again the idea is that the client is involved in the process of monitoring progress and the decision about what to do next. Implementing process and outcome measures gives helpers, consumers, and third party payers a different and reliable way to maximize time, effort, and results. For a complete clinically nuanced discussion of the use of the measures replete with examples, check out On Becoming a Better Therapist. Working with Kids and Families: Using the CORS and CSRS Use the child measures in a similar fashion to the adult measures. There are some differences:  When the child is presented as the problem, use the CORS with the child and parents; do not obtain ORS scores of the parents unless they identify separate problems for themselves.  The measures encourage conversations about similarities and differences; and they allow therapists to attend to each person’s perspective of both change and the alliance. They provide a common ground on which to make comparisons and draw distinctions, allowing each individual to be part of the discussion of what needs to happen next.  It is not unusual for families to hold different perspectives. Using a graph with different- colored lines for each person helps illustrate varying viewpoints and can open up a productive conversation.  The CSRS and SRS give therapists a chance to see which, if any, family members are feeling the least connected to the process. The therapist then has accurate knowledge of where to focus more attention. Using the CORS and ORS with families is an invaluable way to keep track of many change trajectories and many agendas—all it takes is a willingness on the therapist’s part to become adept at seamless data gathering for several people in session and the ability to make that information meaningful by using it as a springboard for conversation. The reward is the same, whether child or family—reliable feedback about whether things are changing and the strength of the alliance, so counseling can better fit client preferences for the best outcome.

20 About Barry: Barry L. Duncan, Psy.D., is a therapist, trainer, and researcher with over 17,000 hours of clinical experience. Dr. Duncan is the director of the Heart and Soul of Change Project, a practice-driven, training and research initiative that focuses on what works in therapy, and more importantly, how to deliver it on the front lines. Barry has over one hundred publications, including fifteen books. His latest books: The Heroic Client (2nd edition, Jossey Bass, 2004); Heroic Clients, Heroic Agencies: Partners for Change (ISTC Press, 2002; Revised 2007 E Edition available at www.heartandsoulofchange.com); Brief Intervention for School Problems (Guilford, 2007); the 2nd edition of the Heart and Soul of Change: Delivering What Works (APA, in press); and the forthcoming, On Becoming A Better Therapist (APA, 2010). He is the co- developer of the Outcome Rating Scale (ORS), Session Rating Scale (SRS), Child ORS, and Child SRS, measures designed to give clients the voice they deserve as well as provide clients, clinicians, administrators, and payers with feedback about the client’s response to services, thus enabling more effective care tailored to client preferences. Because of his self help books, he has appeared on "Oprah,” “The View," and several other national TV programs. His latest self help book, What’s Right With You, challenges the business as usual mentality of “What’s wrong with you” and instead demonstrates how to rally natural resources and resiliencies to overcome life challenges. Barry can be reached at barrylduncan@comcast.net, www.whatsrightwithyou, and www.heartandsoulofchange.com About the Heart and Soul of Change Project (HSCP): The strength of what the client brings to the change process and the impact of the alliance inspired Barry to name the popular book about the common factors as well as this Project—the client is the Heart and the alliance is the Soul of therapeutic transformation. Systematic feedback allows both to be empowered for maximum client benefit. The Project features an international community of helpers of all stripes and flavors as well as researchers and professors, all dedicated to privileging clients and making us better at what we do. The HSCP will also focus on therapist development, not only making us all better at what we do but also encouraging helpers to attend to their professional growth so that they remain a vibrant influence in client lives. The Project provides the portal for entry into the Heroicagency List, where over 800 professionals from all corners of the globe participate in advancing the cause of forming true partnerships with clients, inviting them into the inner circle of decisions about their care. The compass symbolizes what client feedback brings to psychotherapy: The client and therapist are co-adventurers in a journey across uncharted territory. The common factors provide useful directions for this interpersonal and idiosyncratic trip, and specific models and techniques provide well-traveled routes to consider, but feedback offers a necessary compass to provide bearings of the psychotherapy terrain and guidance to the desired destination. MyOutcomes.com and ASIST (www.clientvoiceinnovations.com) Web-based and software outcome management systems that administers and scores the ORS and SRS while providing real time feedback enabling the tailoring of the service to the individual as well as tracking individual and agency effectiveness. The first screen shot below is MyOutcomes and the second is the ASIST program. 20

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640

22 Outcome Rating Scale (ORS) Name ________________________Age (Yrs):____ Sex: M / F Session # ____ Date: ________________________ Who is filling out this form? Please check one: Self_______ Other_______ If other, what is your relationship to this person? ____________________________ Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels. If you are filling out this form for another person, please fill out according to how you think he or she is doing. Individually (Personal well-being) Examination Copy Only I--------------------------------------------------------------------------------------I Interpersonally (Family, close relationships) Examination Copy Only I--------------------------------------------------------------------------------------I Socially (Work, school, friendships) Examination Copy Only I--------------------------------------------------------------------------------------I Overall (General sense of well-being) Examination Copy Only I--------------------------------------------------------------------------------------I © 2000, Scott D. Miller and Barry L. Duncan 22

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640 Session Rating Scale (SRS V.3.0) Name ________________________Age (Yrs):____ ID# _________________________ Sex: M / F Session # ____ Date: ________________________ Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience. Relationship I did not feel heard, I felt heard, understood, and respected. Examination Copy Only I--------------------------------------------------------------------------------------I understood, and respected. Goals and Topics We did not work on or We worked on and talk about what I wanted to work on and Examination Copy Only I--------------------------------------------------------------------------------------I talked about what I wanted to work on and talk about. talk about. Approach or Method The therapist’s The therapist’s approach is not a good fit for me. Examination Copy Only I--------------------------------------------------------------------------------------I approach is a good fit for me. Overall There was something Overall, today’s missing in the session today. Examination Copy Only I--------------------------------------------------------------------------------------I session was right for me. © 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson 0 1 2 3 4 5 6 7 8 9 10

24 Companion Volumes Clinical and Research For For For Clients Schools Agencies Purchase at www.heartandsoulofchange.com 24

Barry Duncan, Psy.D. barrylduncan@comcast.net www.heartandsoulofchange.com www.whatsrightwithyou.com; www.myoutcomes.com 954.721.2981; 561.239.3640

Barryshandouts

by Barry Duncan on Feb 02, 2010

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