Day3KeynoteBarryDuncan

www.heartandsoulofchange.com June 19, 2010 Becoming Better at What We Do Five Steps Barry Duncan, Psy.D. www.heartandsoulofchange.com Psy.D. 954.721.2981 www.whatsrighwithyou.com barrylduncan@comcast.net A Long Time Ago in a Golly! I just want Galaxy Far Away to help people • 17,000 clinical hours ago, I was a starry eyed new therapist….and • As a trainer, I have rubbed elbows with thousands of therapists & the thing that strikes me most is their authentic desire to be helpful. 1

www.heartandsoulofchange.com June 19, 2010 Becoming Better I Want To Help People • The majority of us want to be helpful. And always have—many answered “I want to help people” on school apps. Dissuaded from that answer…not sophisticated and appeared too “co- dependent.” Becoming Better After All There is not much financial incentive—we don’t do this work because we thought we would acquire the lifestyles of the rich and famous. 2

www.heartandsoulofchange.com June 19, 2010 Becoming Better at What We Do More of a Calling • That smart, creative indvs make the sacrifices for advanced degrees only to earn far less than others says something • Required servitude w/o the promise of rags to riches only makes sense b/c it is more of a calling than a job—a quest for meaning & fulfillment But How Do We Get Better? We Have Pursued 3 Paths Personal Therapy Self Awareness Finding the Right Approach Accrued Wisdom From Clinical Experience 3

www.heartandsoulofchange.com June 19, 2010 Personal Therapy/Self Awareness The Royal Road to Better Outcomes? • Personal therapy raises self awareness making us better human beings and better therapists. NOT! Therapy is a good thing, but, and this is a very big but, it doesn’t improve outcomes one iota! Finding the Right Approach Search for the Holy Grail • Because of the field’s emphasis on technique we wind up believing if we just find the Holy Grail, that special model or technique, we will defeat the psychic dragons that terrorize clients 4

www.heartandsoulofchange.com June 19, 2010 But We Soon Discover No Mighty Sword • Why didn’t the powerful sword slay the dragon of misery of the client in my office now? • The answer all too often is to blame ourselves— we are just not measuring up. The Holy Grail seems just out of reach for most of us. The Search for the Holy Grail Doesn’t Do Much for Us • Helping is no more effective now with all our treatment technologies (400 of them) and empirically supported treatments (almost 150 of them) than 40 years ago. • So how can we become better? 5

www.heartandsoulofchange.com June 19, 2010 Experience Is the Best Teacher? 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? • Less experienced achieve about the same results as their more seasoned colleagues. Case in Point: Paul Clement Experience Only Ain’t the Answer • Collected data over 26 yrs • 75% improved—19% dropout; Clement rated • Assumed he improved, but—no more effective than as new grad • Exp. doesn’t necessarily improve outcome. • So how do we get better? 6

www.heartandsoulofchange.com June 19, 2010 Starts With Our Clients My First Client, My First Story • In my first placement at the state hospital. • Tina was like many: young, poor, disenfranchised, heavily medicated, & on the merry-go-round of hospitalizations and at the ripe old age of 22, she was a “chronic schizophrenic.” Learning from Our Clients Thanks Tina • So Tina started my psychotherapy journey and offered up my first lessons: authenticity matters and when in doubt or in need of help, ask the client. Where ever you are Tina, thanks for that great start. • And we sure need their help to improve…Recall 7

www.heartandsoulofchange.com June 19, 2010 We Need Consumer Help The Good, the Bad, & the Ugly • Despite tx efficacy, drop outs are a problem, many do not benefit, therapists vary, don’t know about effectiveness, & there is a crisis of confidence among consumers. To The Rescue Consumer Driven Outcomes Management 8

www.heartandsoulofchange.com June 19, 2010 Feedback and Outcome Now Nine Clinical Trials • All 9 show sig. gains for feedback • A strong case for routine measurement of outcome in everyday clinical practice Becoming Better Recapture Your At Risk Clients • 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… 9

www.heartandsoulofchange.com June 19, 2010 How Therapists Develop Orlinsky & Rønnestad • 5000 therapists • The Pinnacle of Development—Healing Involvement: committed & affirming, high level of empathic skills, conscious Orlinsky, D. E., Rønnestad, M. H. (2005). How psychotherapists develop: of “flow,” feeling effective, Washington, DC: APA. & dealing constructively w/ difficulties. Translating Development Research Five Steps To Accelerate Your Development • 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. • First: Measure outcomes & track your cumulative career development. Monitor effectiveness in service of implementing strategies to improve outcomes. 10

www.heartandsoulofchange.com June 19, 2010 First Source of Acceleration Cumulative Career Development • Improvement in skills, increasing mastery, & surpassing past limitations. • 86% “highly motivated” to pursue prof. dev. • No profession more committed—Therapists want to continue to get better over their careers 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. 11

www.heartandsoulofchange.com June 19, 2010 Cumulative Career Development ASIST and MyOutcomes.com • 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. First Things First Why You Might Be Reluctant • Finding out is risky • What if you find out that you are not so good? What if you are in the wrong profession? • The only way we improve is thru feedback. It takes courage. But so does walking in a room with someone in distress. 12

www.heartandsoulofchange.com June 19, 2010 Feedback Improves Effectiveness C ounselor's O utcom es (n = 30 or more case s) 1 .8 M ean E ffec t S iz e for all C as es 1 .6 1 .4 Effect size 1 .2 1 0 .8 0 .6 0 .4 0 .2 0 4) 4) 7) 5) 9) 8) 5) 0) 8) 8) 7) 7) 1) 1) 0) 9) 7) 5) 4) 1) 1) 0) =9 n=7 n=6 n=6 n=5 n=5 n=5 n=5 n=4 n=4 n=4 n=4 n=4 n=4 n=4 n=3 n=3 n=3 n=3 n=3 n=3 n=3 (n ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 C ounselor Miller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005). The Partners for Change Outcome Management System. Journal of Clinical Psychology, 61(2), 199-208. Regarding Therapist Variability Feedback Improves Outcomes • Norway: 9 of 10 got better outcomes • Feedback raised effectiveness of the lower ones to their more successful colleagues. • Therapist in low effectiveness group became the BEST with feedback! 13

www.heartandsoulofchange.com June 19, 2010 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

www.heartandsoulofchange.com June 19, 2010 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 better therapist. 30-?% Washington DC: American Psychological Association 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

www.heartandsoulofchange.com June 19, 2010 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

www.heartandsoulofchange.com June 19, 2010 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 • Loosen your grip on the “truth” of any approach • Theoretical loyalty brings certainty (certain failure); theoretical promiscuity brings uncertainty (but fits more clients) 17

www.heartandsoulofchange.com June 19, 2010 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. 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. 18

www.heartandsoulofchange.com June 19, 2010 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 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. 19

www.heartandsoulofchange.com June 19, 2010 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. How Do We Attain Currently Experienced Growth • Experiential learning thru clinical work • Beyond cliché, therapists believe that clients are the best teachers—our primary access to Growth 20

www.heartandsoulofchange.com June 19, 2010 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. 21

www.heartandsoulofchange.com June 19, 2010 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. Step Four: You Do What? Identities and Descriptions • Reflect about your identity & construct a story of your work that captures what you do. • Edit and refine your identity & accounts— evolve a description that you can have allegiance to but that doesn’t lead to dead ends. 22

www.heartandsoulofchange.com June 19, 2010 You Do What? Your Identity • Not much help with my identity as therapist; mainly my prof. role as a psych.— Golly! I am a like a dr. but more machinist in a tool scientific, w/o the white and dye shop coat, better than the rest. • Avoided question like the plague; analyze me: didn’t know how to describe it; to prof.: I am a psych., but… You Do What? What is Your Identity? • How do you describe what you do? At your very best, what role do you play with your clients? What recent client represents the essence of your identity, illustrating what you embrace most about your work? 23

www.heartandsoulofchange.com June 19, 2010 The Medical Model Equation Is It Your Identity? Diagnosis + Prescriptive Treatment = Cure or Symptom Amelioration Doesn’t Fit Me, My Experience, or the Data • Not pts with illnesses requiring tx from experts administering powerful interventions. Are not dx or best described by the Killer Ds—diseases, disorders, deficits, disabilities, or dysfunctions. Therapy is not model and technique. • Identity lies outside dx, prescriptive tx, cure, & reflects the interpersonal nature of the work & the consumer’s perspective of the benefit & fit of services. 24

www.heartandsoulofchange.com June 19, 2010 You Do What? The Wizard of Oz L. Frank Baum's wonderful story about life and the resolution of human problems, and believe it or not, therapist identity: Are you a Wizard, Humbug, or Witch. I have been all three. 25

www.heartandsoulofchange.com June 19, 2010 The Wizard Expert, Theory Directed The Wizard, the expert faced with overwhelming problems did what we are trained to do. He prescribed a protracted journey (a technique or medication) for them to acquire something he thought they needed. 26

www.heartandsoulofchange.com June 19, 2010 Theory Directed Just Like I Have assessed problems (The Great & Powerful Oz knows why you have come!), framed them in my favorite theoretical terms, & constructed Interventions w/o collaboration, to provide clients with things I thought they needed. Clients proved themselves worthy, not resistant, by complying. 27

www.heartandsoulofchange.com June 19, 2010 The Humbug Technician, Selling & Delivering ESTs After his embarrassing exposure, the Humbug cleverly addresses the requests of the Scarecrow, Tin Man, and Lion, pulling something out of his black bag for each. They are pleased to receive validation of their desires for completeness, but as the old America song goes, “Oz never did give nothing to the Tin Man, that he didn’t, didn’t already have.” Solutions Out of the Black Bag Just Like I • Have listened to clients’ w/o much collaboration, & delivered interventions from my black bag of reframes, techniques, & ESTs. Sometimes it helped. • Embodies the kind of therapy that is technique-driven—therapist identity is that of a skilled technician delivering the latest ESTs & a salesman of sorts, convincing the client that it is just what is needed. 28

www.heartandsoulofchange.com June 19, 2010 Witches! Always There, Often in Background Glinda helped Dorothy find her own meaning about her perilous quest to Oz, her journey of change, and rely on her own resources to return home, to reach her destination. Although don’t have a magic wand or travel in a bubble, I strive to adopt Glinda’s way to discover what works 29

www.heartandsoulofchange.com June 19, 2010 Personal Description of What You Do Continuous Reflection • Also useful to describe what we do—to define, edit, or outright change it. • Therapist allegiance— believing in rationale and rituals are employed. • Makes sense to describe our work in ways that we believe in & also does not restrict our flexibility. Client Directed, Outcome Informed Personal Description of What You Do • Psychotherapy, a discovery- oriented, non-cookie cutter search for what works. • Feedback provides a comforting compass, a way to manage the uncertainty that is characteristic of therapy as it is of life. 30

www.heartandsoulofchange.com June 19, 2010 You Do What? Discovery Oriented • Thought about discovery, but a new meaning for me. Now has a purpose, a measurable end—a tangible treasure to be found. • The hunt for what works, an increased ORS score; an expedition into what will be beneficial, an exploration of client ideas, myths & rituals, with feedback as the arbiter. You Do What? Co-Explorers • Co-explorers searching for a route of restoration. Multiple opportunities for sharing your respective vantage points while crossing the terrain, stopping to consult your compass to ensure you are headed in the right direction. Often discover trails that we never dreamed existed. 31

www.heartandsoulofchange.com June 19, 2010 You Do What Labor or Art What we do is a measure of who we are. If we imagine our work as labor, we become laborers. If we imagine our work as art, we become artists. Jeffrey Patnaude Becoming Better Why I Love the Work • Foster parents (actual aunt and uncle) trying to do the right thing • Bio parents lost parental rights; dad in jail; both mom and dad poly substance addicted; using while pregnant; many ups and downs; Sara had many dx swirling around head; a real handful • Aunt worried about “attachment” and didn’t know if she could do it anymore; struggling 32

www.heartandsoulofchange.com June 19, 2010 Becoming Better at What We Do The Treasure Chest • Fifth and final step to keep your development in the viewfinder: collecting client notes, cards, and letters about your work with them as well as client stories that mark significant events in your growth as a therapist—the Treasure Chest For the Love of the Work The Treasure Chest • Buffers burnout • Momentary sanctuary • When requirements bring you down • Too many clients in a row not benefiting • Client story hits home…Adam 33

www.heartandsoulofchange.com June 19, 2010 For the Love of the Work Adam: Hi Barry I wanted to write you and let you know what was happening and to say thanks. As you know I fulfilled the obligations of my parole and joined the Army (Thanks for the letter!). I just made corporal and things are going well for me. I am told that I am sergeant material and I intend to take college courses when I get stationed after infantry training. But what I really wanted to tell you about was my barracks. The Army has lots of different kinds of people. In fact, I am the minority here. Most of the guys in my unit are black or Hispanic. And that’s the thing I wanted to tell you. I see their uniform first before I notice whether they are white or not. I see them as my team and I will watch their backs like I know they will watch mine. My best friend in my unit is a Mexican-American guy from Texas. We have had some great discussions about racism and he came from a real poor background, probably even worse than me. He has gone through some real hard times with white people. So, thanks Barry. Thanks for not giving up on me, for putting up with my bullshit, and for seeing that I was capable of something different. I see now that you didn’t (pre) judge me just the way that I now don’t prejudge others. For the Love of the Work The Treasure Chest • These unsolicited notes, letters, and cards have sustained me in tough moments as a therapist. Over the years, I added another dimension, my reflections about the clients who taught me the most about being a psychotherapist, a narrative account of my development as told thru my experiences with clients. 34

www.heartandsoulofchange.com June 19, 2010 For the Love of the Work Becoming Better at What We Do • If you got into this business because you wanted to help people, you already have what it takes. 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—your love of the work provides the rest. 35

Day3KeynoteBarryDuncan

by Barry Duncan on Jun 05, 2010

Accessibility

Categories

Tags

Upload Details

Usage Rights

1 Embed 26

Statistics

Day3KeynoteBarryDuncan — Document Transcript