The Most Important Findings
of the Last 30 Years
Barry Duncan, Psy.D. www.heartandsoulofchange.com
The Four Greatest Hits
The Two Greatest Disasters
The Dodo Bird Verdict
The Dodo Verdict
•With few exceptions, partisan studies
designed to prove the unique effects
of a given model have found no
differences—nor has recent meta-
analyses…The Dodo Verdict—the
most replicated finding in the
“Everybody has won and all
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 fide
psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215.
The Treatment of Depression
Collaborative Research Project (TDCRP)
•Considered to be the most sophisticated comparative
clinical trial ever conducted:
•Four approaches (CBT, IPT, Drug, Placebo).
•No difference in outcome between approaches
•The client’s rating of the alliance at the second session
the best predictor of outcome across conditions.
•Tx model accounted for (0-2% of the variance…
Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General
Psychiatry, 46, 971-82.
Project MATCH and the Alliance
•The largest study ever conducted on the treatment of
•Three different treatment approaches studied (CBT, 12-step,
and Motivational Interviewing).
•NO difference in outcome between approaches.
•The client’s rating of the therapeutic alliance the best
•Drinking behavior during treatment;
•Drinking at 12-month follow-up.
Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29.
Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK.
Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and
outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98.
The Dodo Also Rules Family Therapy
Cannabis Youth Treatment Project
•600 Adolescents marijuana users:
•Significant co-morbidity (3-12 problems).
•Two arms (dose, type) and one of
three types of treatment in each arm:
•Dose arm: MET+CBT (5 wks),
MET+CBT (12 wks), Family Support
Network (12 wks)+MET+CBT;
•Type arm: MET/CBT (5 wks), ACRT (12
weeks), MDFT (12 wks).
Approach accounted for 0% of the variance in outcome. Ratings of the
alliance predicted: Premature drop-out; Substance abuse and dependency
symptoms post-treatment, and cannabis use at 3 and 6 month follow-up.
Tired of RCTs…The Dodo
in the Real World
1999 study of 2000 providers and over
20,000 clients; 13 different orientations
including CBT, SFBT, family therapy,
medication, and eclectic…
2006 study of 1309 clients compared six
groups: CBT, PCT or PDT only, and one of
these plus one additional approach
(integrative, supportive, art)
NO DIFFERENCE! In the UK study, all
groups made marked improvement (ES =
1.36). Approach and purity accounted for
tiny proportions of variance (1% & 0.5%.
Stiles, W. B., Barkham, M., Twigg, E., Mellor-Clark, J., & Cooper, M. (2006). Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies
as practised in UK National Health Service settings Psychological medicine 36, 555-566.
Brown, J., Dreis, S., & Nace, D.K. (1999). What really makes a difference in psychotherapy outcome? Why does managed care wa nt to know? In
M.A. Hubble, B.L. Duncan, and S.D. Miller (Eds.). The heart and soul of change: What works in therapy.. Washington, D.C.: APA Press, pp. 389-406.
Implications of the Dodo Bird Verdict
All approaches work because
of factors common to all:
Of the client’s abilities
Client resources transcend
Time better spent recruiting
what clients already have than
assessing what they need
Factors Accounting for
Lambert, M. (1986). Implications of Psychotherapy Outcome Research for Eclectic Psychotherapy.
In J. Norcross (Ed.) Handbook of Eclectic Psychotherapy. New York: Brunner/Mazel.
Client/Extratherapeutic Factors (87%)
Treatment Effects 38-54%
Therapist Effects Expectancy/Allegiance
46-69% Rationale/Ritual (General
The Killer D’s of
Not Reliable or Valid
None ever related to
Clients Are the Lions of Change
Until lions have their
historians, tales of
hunting will always
glorify the hunter.
The Power of the
• Relational Bond
• Agreement on goals
38-54% • Agreement on tasks
Seven Times the Impact of
for Most of Therapist
Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass
Over 1000 Research Findings
Quality of the alliance more
potent predictor of outcome than
orientation, experience, or
professional discipline-- recall
TDCRP, MATCH, CYT.
Clients rarely report negative
reactions before deciding to
Same holds true for youth and
Research into Practice
•Increasingly, the relationship is
viewed as merely “setting the stage”
for the “real” treatment:
•Confronting distorted thoughts;
•Recovering forgotten memories;
•Asking special questions;
•Tapping on or waving fingers in front of the
face…but the data say:
•The alliance deserves far
Duncan, B. (2010). On becoming a better therapist. Washington, DC: APA.
Greatest Hits: The Alliance
Theory of Change
A Client Example Meaning or
Client’s View of the
The Predictive Power
of Early Change
Greatest Hits : Project Match
Babor, T.F., & DelBoca, F.K. (eds.) (2003). Treatment Matching in Alcoholism. United Kingdom: Cambridge, 113.
Greatest Hits: Early Change
Cannabis Youth Treatment Project
Early Change Predicts…
In a study of more than 2000 therapists,
Brown found that if no improvement
occurred by the sixth visit, then no
improvement was likely over the entire
course of treatment.
Clients who worsened by the third visit
were twice as likely to drop out than
those reporting progress.
Variables such as diagnosis, severity, and
type of therapy were, “not . . . as
important [in predicting eventual
outcome] as knowing whether or not the
treatment being provided [was] actually
Feedback about outcome is essential
for clinical decision making.
Do not need to know what tx to use
for a given diagnosis as much as
whether the current relationship is a
good fit and providing benefit, and,
if not, to adjust early to maximize
the chances of success.
(more than anything else)
Greatest Hits: Client Feedback
One study of 6224 clients, Miller,
Duncan et al (2006) provided
therapists with real-time feedback
regarding the client’s experience
of the alliance and progress.
This “practice-based evidence” not
only resulted in higher retention
rates but also doubled the overall
effect size of services offered
(baseline ES = .37 v. final phase
ES = .79; p < .001). Download
these measures for free…
The Revolutionary Benefits
As incredible as the results appear, they are
entirely consistent with other findings.
Lambert et al. (2003) reported that those
relationships at risk which received formal
feedback were better off than 65% of those
without feedback (Average ES = .39!).
Whipple et al. (2003) found that clients
whose therapists had access to outcome and
alliance info were less likely to deteriorate,
and twice as likely to achieve change.
Obtained without any attempt to control
Effects on Efficiency
Cancellations, No Shows, LOS
Claude (2004) compared the ave. # of
sessions, canc., no shows, and % of long-
term cases before and after OM. Sample:
2130 closed cases seen in a public CMHC.
Ave. # of sessions dropped 40% (10 to 6)
while outcomes improved by 7%; canc. and
no show rates were reduced by 40% and
25%; and % of long term null cases
diminished by 80% (10% to 2%).
An estimated savings of $489,600. Such cost
savings did not come at the expense of client
satisfaction with services—during the same
period satisfaction rates improved
“I have found little
that is good about
human beings. In my
experience, most of
them are trash.”
--Sigmund Freud, M.D.
Sicker With Each Passing Year
DSM 1952 - 1994
DSM II DSM
III R IV
Educate the People: You Are Sick
Now "free mental health check ups”
like National Depression Day or
National Anxiety Day.
Largely funded by drug companies and
sponsored by MH prof. org—should be
Cultivated a curious change.
Unhappiness not shaped by diverse
forces. No, problems are because
people are diseased, disordered,
dysfunctional, disabled, and have
deficits…the Killer Ds
Mental Health Screening Test
1. Lift your right foot off the
floor and make clockwise
2. Now, while doing this, draw
the number "6" in the air
with your right hand.
3. If your foot changes
direction, you need drugs or
therapy or both.
And the Message Works!
If drug txs for mental “disorders”
were books, they would be
Last year, more than 150 million
pres. were written for anti-dep.—
more than $14 billion spent; 20
million pres. for Ritalin,
surpassing the amount spent for
Diagnostic Dys- Order
Does not predict LOS or outcome
Little help in treatment selection
Surveys consistently find that
therapists do not like it or find it
Kirk, S.A., & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine
Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass.
Evidence Based Practice
The intent here is not to
approach can be just the
ticket for a particular client—
but rather expose its
limitations because it is often
wielded as a mandate for
competent and ethical
practice. Such edicts are
gross misrepresentations of
the data and blatant misuses
of the evidence.
Greatest Disasters: EBP
•Dodo Verdict highlights fatal
flaw: Efficacy over placebo or
TAU is not efficacy over other
approaches; and unremarkable;
•The differences which have been
•Do not exceed what would be expected by
•Accounts for 1% of the variance.
•And as a mandate
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 fide psychotherapies: Empirically,
"All must have prizes." Psychological Bulletin, 122(3), 203-215.
A Mountain of Manure
The “Evidence” of
Evidence Based Practice
Must always ask,
“Whose” evidence is it?
“What kind” of
evidence is it? (Is it
just efficacy over
Like Bikini Wear
Bikinis and Allegiance:
Whose Evidence Is It?
At least 40% of any
observed effect is
attributable to the belief
in (allegiance to) the
approach by the
Bikinis and Unfair Comparisons:
What Kind of Evidence Is It?
Is the study really a fair contest?
E.g., CBT v PDT
TAU: Pet approach of the
researcher, handpicked and
trained therapists with special
supervision (reduced caseloads)
will always outperform TAU.
The exorbitant cost better spent
on reducing caseloads, supporting
ther. with sup., feedback about
outcome, and training in models of
Smoke and Mirrors
Dialetical BT for “BPD”
Of 382 eligible by dx, only
25 (6.5%) thought it was for
them; 25% of those
dropped out before program
started; another 25%
For those remaining, was
effective, but once again,
not fitting the hype or the
expense of implementation
And the conclusion…
EBP Is A Humbug
APA Definition of EBP
Evidence-based practice is
the integration of the best
available research with
clinical expertise in the
context of client
Clinical decisions should be made in
collaboration with the client,
based on the best clinically relevant
evidence, and with consideration for
the probable costs, benefits, and
available resources and options
Services are most effective
when responsive to the client’s
specific problems, strengths,
context, and preferences.
The application of research
evidence always involves
probabilistic inferences. Therefore,
ongoing monitoring of client
progress and adjustment of
treatment as needed are essential.
Final Thoughts: The Borg?
No--need not be warring
factions; Captain Picard not
really fighting the Borg
EBP is a worthy endeavor--but
broaden the definition (APA)
Evidence based on 40 years
of outcome research and the
known predictors of success
And the best evidence of all—
the feedback about fit and
progress we get from clients
Greatest Hits: Summary
No One Approach Works
Better than Another...the
Client Is The Lion of Change
The Alliance Predicts Outcome…
Early Change Predicts Outcome…
Using Client Feedback, or PBE,
Improves Effectiveness and