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Molly Explains It All


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This slide show presents the story of the incomparable Molly, a veteran of failed therapy, and how she ultimately triumphs when given a chance to enlist her own resources and apply her own ideas about …

This slide show presents the story of the incomparable Molly, a veteran of failed therapy, and how she ultimately triumphs when given a chance to enlist her own resources and apply her own ideas about change.

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  • 1. www.heartandsoulofchange,.com 6/10/2010 What Makes Psychotherapy Work? Molly Explains It All Barry Duncan, Psy.D. Psy.D. 954.721.2981 1
  • 2. www.heartandsoulofchange,.com 6/10/2010 •Since the 60’s, the # of models has grown from 60 to over 400… •Each claims superiority in conceptualization and outcome The result is fragmentation along theoretical and disciplinary lines Now over 100 so called evidence based treatments, but ironically… 2
  • 3. www.heartandsoulofchange,.com 6/10/2010 Battle of the Brands •Cognitive Therapy •Behavioral Therapy •Client-centered Therapy Client- •Cognitive Behavioral Therapy •Systemic Therapy •Motivational Interviewing •Biopsychosocial Therapy •Twelve Steps •Solution-focused Therapy Solution- •Dialectical Behavioral Therapy •Multimodal Therapy •Multidimensional Family Therapy •Psychodynamic Therapy •Structural Family Therapy •Narrative Therapy •Functional Family Therapy •Integrative Problem-Solving Therapy Problem- •Skills Training •Eclectic Therapy •Acceptance and Commitment Therapy •Interpersonal Psychotherapy •Existential Therapy •Transtheoretical Therapy The Dodo Verdict •With few exceptions, partisan studies designed to prove the unique effects of a given model have found no differences— differences—nor has recent meta- meta- analyses…The analyses…The Dodo Verdict—the Verdict— most replicated finding in the psychological literature “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. 3
  • 4. www.heartandsoulofchange,.com 6/10/2010 TDCRP The Alliance •Considered most sophisticated comparative clinical trial ever: •CBT, IPT, Drug, Placebo •No difference in outcome •The client’s rating of the alliance at the second session the best predictor of outcome across conditions. Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82. Project MATCH—Largest Ever The Alliance •CBT, 12-step, & Motivational 12- Interviewing •NO difference in outcome •The client’s rating of the alliance the best predictor of: Treatment participation; Drinking behavior during treatment; Drinking at 12-month FU 12- Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29. 58, 7- 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 and of Consulting and Clinical Psychology, 65(4), 588-98. 65(4), 588- 4
  • 5. www.heartandsoulofchange,.com 6/10/2010 The Dodo Also Rules Family Therapy Cannabis Youth Treatment Project •600 Adolescents marijuana users: •Rated as or more severe than adolescents seen in routine clinical practice settings; •Significant co-morbidity (3-12 problems). co- (3- •Participants randomized into one of 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). The Results Cannabis Youth Treatment Project •Treatment approach accounted for little more than 0% of the variance in outcome. •By contrast, ratings of the alliance predicted: •Premature drop-out; drop- •Substance abuse and dependency symptoms post-treatment, post- and cannabis use at 3 and 6 month follow-up. follow- Tetzlaff, B., Hahn, J., Godley, S., Godley, M., Diamond, G., & Funk, R. (2005). Working alliance, treatment satisfaction, and post-treatment patterns of use among adolescent substance users. post- Psychology of Addictive Behaviors, 19(2), 199-207. 199- Shelef, K., Diamond, G., Diamond, G., Liddle. H. (2005). Adolescent and parent alliance and treatment outcome in MDFT. Journal of Consulting and Clinical Psychology, 73(4), 689-698. 689-698. 5
  • 6. www.heartandsoulofchange,.com 6/10/2010 Implications of the Dodo Bird Verdict All 400 therapeutic approaches work because: Of factors common to all models Client resources and the alliance transcend technique Time better spent recruiting what clients already have and building strong alliances, but.. Diagnosis “I have found little that is good about human beings. In my experience, most of them are trash.” --Sigmund Freud, M.D. 6
  • 7. www.heartandsoulofchange,.com 6/10/2010 The Killer D’s of Client Diminishment Dysfunction Disorder Disability Disease Deficit Damaged Not Reliable or Valid None ever related to outcome Factors Accounting for Successful Outcome 40.0% Spontaneous Remission Client/Extratherapeutic Common Factors Relationship Models/Techniques 30.0% 15.0% Placebo/Hope/Expectancy 15.0% Lambert, M. (1986). Implications of Psychotherapy Outcome Research for Eclectic Psychotherapy. In J. Norcross (Ed.) Handbook of Eclectic Psychotherapy. New York: Brunner/Mazel. 7
  • 8. www.heartandsoulofchange,.com 6/10/2010 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) 30-?% When Recovery Is Expected Clients Are the Lions of Change Until lions have their historians, tales of hunting will always glorify the hunter. African Proverb 8
  • 9. www.heartandsoulofchange,.com 6/10/2010 Molly: A Lion of Change Godzilla View of Clients  Diminishes our ability to recruit client resources  Consider Molly’s dx and labels:  Separation Anxiety Disorder  Dysfunctional Family  Mother with Borderline tendencies 9
  • 10. www.heartandsoulofchange,.com 6/10/2010 Relationship Factors The Alliance: • Relational Bond • Agreement on goals 38- 38-54% • Agreement on tasks Seven Times the Impact of Model/Technique…Accounts for Most of Therapist Variance Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass The Alliance: 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 terminate.  Same holds true for youth and family therapy 10
  • 11. www.heartandsoulofchange,.com 6/10/2010 Research into Practice The Alliance •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 more RESPECT… Duncan, B. (2010). On becoming a better therapist. Washington, DC: APA. Reliance On The Alliance • Be friendly, responsive, and flexible (like a first date). • Empathy and Positive Regard: Validate. Legitimize the client’s concerns/basic worth and the importance of their struggle. • Work on client’s goals period. • Fit the client’s theory of change. 11
  • 12. www.heartandsoulofchange,.com 6/10/2010 The Client’s Theory of Change Pre- Pre-existing beliefs about the problem and change Source: Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the Rules. New York: Guilford. When the alliance is in trouble… Consider… 12
  • 13. www.heartandsoulofchange,.com 6/10/2010 Molly The Therapeutic Alliance The Alliance Goals, Means or Meaning Methods: or Theory of Purpose Change Client’s View of the Relationship 13
  • 14. www.heartandsoulofchange,.com 6/10/2010 Molly Addresses Psychotherapy’s Greatest Disaster Evidence Based Practice Psychotherapy Research’s 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 found: •Do not exceed what would be expected by chance; •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. 6, 412- Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, meta- "All must have prizes." Psychological Bulletin, 122(3), 203-215. 122(3), 203- 14
  • 15. www.heartandsoulofchange,.com 6/10/2010 The “Evidence” of Evidence Based Practice  Must always ask, “Whose” evidence is it? and  “What kind” of evidence is it? (Is it just efficacy over placebo?)  Because… Allegiance: Whose Evidence Is It?  At least 40% of any observed effect is attributable to the belief in (allegiance to) the approach by the researchers  Even meager differences disappear when researcher allegiance is controlled… 15
  • 16. www.heartandsoulofchange,.com 6/10/2010 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 their choice. Conclusion: EBP is a Humbug EBP offers choices for clients—but are not what they are cracked up to be. And what does Molly say about EBP? She received exposure therapy for her anxiety problem… 16
  • 17. www.heartandsoulofchange,.com 6/10/2010 Molly and Client Preferences APA Definition of EBP Evidence-based practice is the integration of the best available research with clinical expertise in the context of client characteristics, culture, and preferences (American Psychologist, May 2006). 17
  • 18. www.heartandsoulofchange,.com 6/10/2010 APA Recommendations  Clinical decisions should be made in collaboration with the client, based on the best clinically relevant evidence  Services most effective when responsive to the client’s strengths, cultural context, and preferences.  Responses are variable. Therefore, ongoing monitoring of client progress and adjusting as needed is essential. The Debacle with Molly Could Have Been Prevented… Prevented… •Client’s rating of the alliance the best predictor of engagement and outcome. •The client’s subjective experience of change early in the process the best predictor of success for any particular pairing. 18
  • 19. www.heartandsoulofchange,.com 6/10/2010 How to Improve Outcome: Integrating Formal Client Feedback into Care The O.R.S The S.R.S Download free working copies at: The Benefits of Outcome Management  One study of 6224 clients, Miller, Duncan, Brown, Sorrell, and Chalk (in press) provided therapists with ongoing, 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). 19
  • 20. www.heartandsoulofchange,.com 6/10/2010 The Revolutionary Benefits  As incredible as the results may appear, they are entirely consistent with other findings.  Lambert et al. (2003) reported that those relationships at risk for a negative outcome which received formal feedback were, at the end of therapy, better off than 65% of those without feedback (Average ES = .39, p < .05).  Whipple et al. (2003) found that clients whose therapists had access to outcome and alliance information were less likely to deteriorate, and twice as likely to achieve a clinically significant change. 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 significantly. 20
  • 21. www.heartandsoulofchange,.com 6/10/2010 Where This Is Headed  Software and web- based systems for therapists and agencies to track outcome and provide real time feedback— checkout ASIST and 21
  • 22. www.heartandsoulofchange,.com 6/10/2010 Final Thoughts: Molly’s Lessons Molly Did Explain It ALL!  The Client’s Resources, Resiliencies, and Support Network  The Client’s View of the Alliance  The Client’s Theory of Change— their ideas of how they can be helped  The Client’s View of Progress 22