OnBecomingCh5DiscussionSlides

www.heartandsoulofchange.com 11/23/2010 On Becoming a Better Therapist Chapter Five Discussion Barry Duncan, Psy.D. www.heartandsoulofchange.com Psy.D. 954.721.2981 www.whatsrighwithyou.com barrylduncan@comcast.net 1

www.heartandsoulofchange.com 11/23/2010 Winter Getaway! Training of Trainers  HSCP Training of Trainers (TOT): Jan. 31- Feb. 4, 2011 (24 hours of CEs) This intensive training experience gives you all you need to train others and implement CDOI. And it provides the first step in becoming an HSCP Certified Trainer of CDOI. 2

www.heartandsoulofchange.com 11/23/2010 I Admit It I’m a Snob  Not about money, possessions, wine, food, coffee, social status, etc. I am a snob about therapy, the work I love, & about who teaches me about it, and… Rock Stars But Haven’t Done Much Therapy Some of the biggest workshop stars have minimal therapy experience…some have not held one full time therapy gig—went from graduate school to doing workshops based on luck of assoc. with famous folks and/or ability to put on a good show. 3

www.heartandsoulofchange.com 11/23/2010 And Then. There Are the Researchers  Should be consumed & translated by clinicians. Goal…  But I get a chaffed when they presume too much—what therapists should do. Meta- analysis & HLM only go so far.  Not saying that there isn’t much to learn, just that I am a snob about psychotherapy and who teaches me about it. Chapter 5 My Voice in Hopeful Harmony  with the best of what research has to offer. This chapter picks up on the discussion of cumulative career development and offers empirically- based suggestions for improving your work 4

www.heartandsoulofchange.com 11/23/2010 Chapter 5 Brings You The Heart and Soul of Change  What the client brings to therapy and the impact of the alliance gave rise to the name I gave the co-edited book about the common factors—the client is the heart and the alliance is the soul. Your focus on these primary sources, in conjunction with attaining client feedback is the best way to accelerate your development—the biggest bang for your buck. 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 5

www.heartandsoulofchange.com 11/23/2010 Becoming Better Bottom Line “The quality of Suggests a the patients participation . . . different focus [emerges] as Enlist, harvest, the most important rally, recruit client determinant of resources to the outcome." cause of change Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of process -outcome research: In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 307-390). New York: Wiley. Clients Are the Lions of Change Until lions have their historians, tales of hunting will always glorify the hunter. African Proverb 6

www.heartandsoulofchange.com 11/23/2010 Casting the Client in Heroic Roles  No formula here, more of an attitude requiring a balance between listening empathically with mindfulness toward resources that you know are there.  Identify not what clients need, but what they already have in their world that can be put to use in reaching their goals Finding the Heroic Client What are the qualities that describe you when you are your very best? What were you doing when these aspects became apparent to you? What kind of person do these aspects describe? Or, What kind of person do these aspects show an aspiration toward? What are the qualities that others would describe In you when you are at your very best? What were you doing when they noticed these aspects? What kind of person do these aspects describe? Or, what kind of person do these aspects show an aspiration toward? 7

www.heartandsoulofchange.com 11/23/2010 Finding the Heroic Client  Who was the first person to tell you that they noticed the best of you in action? What were you doing when they noticed these aspects?  Who was the last person to tell you that they noticed the best of you in action? What were you doing when they noticed these aspects?  Who in your life wouldn’t be surprised to see you stand up to these situations and prevail? What experiences would they draw upon to make these conclusions about you? What “quintessentially you” stories would they tell?...Kim  When I am at my very best, I am _____________. Telling Heroic Stories  What are the obvious and hidden strengths, resources, resiliencies, and competences contained in the client’s story?  What are the competing stories—the stories of clarity, coping, endurance, and desire that exist simultaneously with the confusion, pain, suffering, and desperation?  What is already there to be recruited for change? The Heroic Client 8

www.heartandsoulofchange.com 11/23/2010 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  Many ways to learn to engage client strengths Clients The Heart of Change Client outcome feedback makes consumers the historians of their own change Partnering w/clients to monitor outcome engages most the potent factor of change 9

www.heartandsoulofchange.com 11/23/2010 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 Therapists Variables that Predict Change Therapists with the best results:  Are better at the alliance across clients; alliance Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, ability accounts for therapist differences 75(6), 842-852.; Anker, Owen, Duncan, & Sparks (2010). The alliance in couple therapy. Journal of Consulting and Clinical Psychology. Owen, Duncan, Anker, & Sparks (2010). Therapist variability in couple therapy. Manuscript submitted for publication. 10

www.heartandsoulofchange.com 11/23/2010 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 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 11

www.heartandsoulofchange.com 11/23/2010 Project MATCH What about the mandated clients? •No difference in outcome between voluntary and mandated clients. •The only reliable predictor? •The Alliance Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7- 29. 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. Model Maniacs Arguments Against the Alliance •Findings only correlational, even though over 1000 reported associations…like argument about smoking cigarettes & cancer! •Don’t know direction of the correlation—the chicken or the egg: does change cause high alliance ratings or does a high alliance cause change 12

www.heartandsoulofchange.com 11/23/2010 Disentangling the Alliance-Outcome Correlation Anker, Owen, Duncan, & Sparks Alliance (2010). The alliance in couple therapy. Journal of Consulting and Clinical Psychology, 78(5), 635-645. Alliance score at session 3 predicts outcome over and above the effects of early symptom change...The alliance creates change and is not just an artifact of it. 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. 13

www.heartandsoulofchange.com 11/23/2010 Alliance As An Overarching Framework The Alliance is the Soul  Transcends any beh & is a property of all—from tech. to scheduling appt  Purpose is to engage in purposive work  Have to earn it each & every time; alliance is our craft; practice elevates to art The Therapeutic Alliance The Alliance Goals, Means or Meaning Methods: or Theory of Purpose Change Client’s View of the Relationship 14

www.heartandsoulofchange.com 11/23/2010 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. Attitude Important Alliance is Central Filter  Is what I am doing and saying now building or risking the alliance?  Doesn’t mean you can’t challenge but rather that you have to earn the right and, consider the alliance consequences 15

www.heartandsoulofchange.com 11/23/2010 Bottom Line There Are Many Ways  To understand & apply relationship skills and research offers key guidelines regarding what is important to outcome from the client’s point of view.  Take on your relational skills as a project, the central symbol of your development. Try on the different systems of skills for size and watch your outcomes improve as you refine ways to purposefully involve your clients in the work. The Alliance The of Change Alliance feedback enables a fit between client expectations, preferences, and services Does not leave the alliance to chance—applying over 1000 studies showing the relationship of the alliance to positive outcomes 16

www.heartandsoulofchange.com 11/23/2010 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-?% Interdependent & overlapping: Technique is the alliance in action, an explanation for the client’s difficulties & a remedy for them—an expression of the therapist’s belief that it could be helpful in hopes of inspiring the same response in the client. Cannot have an alliance w/o a tx, an agreement about how therapy will address client goals. Similarly, you can’t have a positive expectation for change w/o a credible way for both the client & therapist to understand how change can happen. Feedback As A Common Factor  Overlaps with & affects all factors—tie that binds  Soliciting feedback is a living, process that engages clients in monitoring outcome, heightens hope, fits client preferences, maximizes therapist-client fit, and is itself a core feature of change. 17

www.heartandsoulofchange.com 11/23/2010 You Can Be Proactive in Other Ways By focusing on what is known about the common factors, especially the heart and soul of change. Working on harvesting client resources and securing strong alliances is a great place to start (and continue) to grow as a therapist. 18

OnBecomingCh5DiscussionSlides

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