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Chapter One of On Becoming a Better Therapist.

Chapter One of On Becoming a Better Therapist.



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OnBecomingABetterTherapistCh1 OnBecomingABetterTherapistCh1 Document Transcript

  • 1 n. SO YOU WANT TO BE A tio bu BETTER THERAPIST tri is rD fo ot N d. ve er es R The only man I know who behaves sensibly is my tailor; he takes my s ht measurements anew each time he sees me. The rest go on with their old ig measurements and expect me to fit them. R —George Bernard Shaw ll n .A tio ia While I often don’t remember where I leave my glasses, I still vividly oc recall my first client, including her full name, but I’ll call her Tina. A long ss lA time ago in a galaxy far way, I was in my initial clinical placement in gradu- ca ate school at the Dayton Mental Health and Developmental Center, the gi state hospital in Ohio. This practicum was largely, if not totally, intended to lo be an assessment experience. After all, you don’t really do therapy with those ho folks, do you? Tina was like a lot of the clients: young, poor, disenfranchised, yc heavily medicated, and on the merry-go-round of hospitalizations—oh, and Ps similar to her fellow patients, at the ripe old age of 22, she was called a an “chronic schizophrenic.” ic er I gathered up my Wechsler Adult Intelligence Scale-Revised (WAIS), Am the first of the battery of tests I was attempting to gain competence with, and was on my merry but nervous way to the assessment office, a stark, run-down ht rig room in a long-past-its-prime, barrack-style building that reeked of cleaning y fluids overused to cover up some other worse smell, the institutional stench. Butop on the way I couldn’t help but notice all the looks I was getting—a smirk fromC an orderly, a wink from a nurse, and funny-looking smiles from nearly everyone 3 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • else. My curiosity piqued, I was just about to ask what was going on when the chief psychologist, a kindly old guy (he was probably younger than I am now) who likely stayed in the state system long after he knew he should leave, put his hand on my shoulder and said, “Barry, you might want to leave the door open.” And I did. I greeted Tina, a young, extremely pale woman with short, brown, n. cropped hair (who might have looked a bit like Mia Farrow in the Rosemary’s tio Baby era had Tina lived in friendlier circumstances), and introduced myself bu in my most professional voice. Before I could sit down and open my test kit, tri is Tina started to take off her clothes, mumbling something indiscernible. I just rD stared in disbelief, in total shock really. Tina was undaunted by my dismay fo and quickly was down to her bra and underwear when I finally broke my ot silence, hearing laughter in the distance, and said, “Tina, what are you N doing?” Tina responded not with words but with actions, removing her bra d. ve like it had suddenly become very uncomfortable. So, there we were, a gradu- er ate student, speechless, in his first professional encounter, and a client sitting es nearly naked, mumbling now quite loudly but still nothing I could under- R stand, and contemplating whether to stand up to take her underwear off or s simply continue her mission while sitting. ht ig Finally, in desperation, I pleaded, “Tina, would you please do me a big R favor? I mean, I would really appreciate it.” She looked at me for the first time, ll .A looked me right in the eye, and said, “What?” I replied, “I would really be grate- n io ful if you could put your clothes back on and help me get through this assess- t ia ment. I’ve done them before, but never with a client, and I am kinda freaked oc out about it.” Tina whispered, “Sure,” and put her clothes back on. And ss although Tina struggled with the testing and clearly was not enjoying herself, lA she completed it. I was so genuinely appreciative of Tina’s help that I told her ca she really pulled me through my first real assessment. She smiled proudly, and gi lo ultimately smiled at me every time she saw me from then on. I wound up get- ho ting to know Tina pretty well and often reminded her how she helped me, yc and I even told her that I thought she looked like Mia Farrow, which she Ps immensely enjoyed. Every time she left the hospital, I hoped that I would an never see her again—but I did. ic Later that day, the chief psychologist caught up with me and asked me er how I got Tina to put her clothes back on and complete the WAIS. He added Am that others had either just walked out of the room or simply commanded Tina ht to put on her clothes. One time, he said, Tina responded aggressively to the rig commands and was put in restraints. The psychologist smiled a patronizing yop smile that said “someday you’ll understand” and reported that Tina was a sortC of rite of passage for the psychology trainees. In truth, I was angry but I didn’t say anything about that to him. I replied that all I did was to ask her to do me 4 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • a favor and help me out. The chief psychologist said, “Good approach,” and walked off.1 So Tina started my psychotherapy journey and offered up my first les- sons for consideration: authenticity matters and when in doubt or in need of help, ask the client. Wherever you are, Tina, thanks for the great start. This book reflects these lessons and highlights the value of transparency and true n. partnerships with clients. tio I am a true believer in psychotherapy and in therapists of all stripes bu and flavors. In my 30 years and 17,000 hours of experience with clients, I tri is have been privileged to witness the irrepressible ability of human beings to rD transcend adversity—clients troubled by self-loathing and depression, bat- fo tling alcohol or drugs, struggling with intolerable marriages, terrorized by ot inexplicable voices, oppressed by their children’s problems, traumatized by N past or current life circumstances, and tormented with unwanted thoughts d. ve and anxieties—with amazing regularity. As a trainer and consultant, I have er rubbed elbows with thousands of psychotherapists across the globe, and the es thing that strikes me most is their authentic desire to be helpful. Regardless R of discipline, theoretical persuasion, or career level, they really care about s ht people and strive to do good work. The odds for change when you combine ig a resourceful client and caring therapist are worth betting on, certainly R cause for hope, and responsible for my unswerving faith in psychotherapy ll .A as a healing endeavor. n The overwhelming majority of psychotherapists, as corny as it sounds, tio ia want to be helpful. Many of us, including me, even answered in graduate oc school applications “I want to help people” as the reason we chose to be thera- ss pists (see Figure 1.1). Often, some well-meaning person dissuaded us from that lA answer because it didn’t sound sophisticated or appeared too “codependent.” ca Such aspirations, however, are not only noble but also can provide just what gi is needed to improve your effectiveness. After all, there is not much finan- lo ho cial incentive for doing better therapy—we don’t do this work because we yc thought we would acquire the lifestyles of the rich and famous. It is amazing Ps to think, in these hard economic times, that smart, creative individuals an make the necessary sacrifices to attain advanced degrees only to earn far less ic money than those with comparable degrees in other fields. It says something er Am ht 1Although I didn’t consider it while it was happening, the gender politics of this situation are noteworthy. rig Later, and over time, I talked with Tina about what taking off her clothes meant. Two ways of under- y standing her behavior emerged from our discussions. First, disrobing in the face of male authority andop pressure to perform usually ended the encounter—it allowed her to exert some control over a continualC demand for compliance. Second, it was a way that Tina learned to prevent brutal physical abuse by her father. In effect, Tina learned to trade sexual abuse for beatings. When I conveyed the meanings of Tina’s behavior as well as my palpable annoyance, it ended the staff’s use of Tina as “a rite of passage.” SO YOU WANT TO BE A BETTER THERAPIST 5 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • I just want to help people! n. tio bu tri is rD fo ot N d. ve er es R s ht ig R ll n .A tio ia oc ss lA ca gi lo ho yc Ps an ic er Figure 1.1. Barry just wanted to help people. Am ht quite good about us and our career choice, although less kind interpretations rig are readily available. yop Doing the required servitude without the promise of a rags-to-richesC future only makes sense because being a psychotherapist is more of a calling than a job—a quest for meaningful activity and personal fulfillment (Orlinsky et al., 2005). Parks (1996, p. 12) summarizes: 6 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • Accounts by psychotherapists of their professional [work] suggest that the feelings they experience while practicing therapy are very important in motivating their therapeutic work and that, generally, therapists enjoy working with patients and derive a deep sense of personal satisfaction from doing therapy (Dryden & Spurling, 1989; Guy, 1987). That these feelings are intrinsically satisfying, and not a reward on a par with money or profes- n. sional prestige, is evident from the terms that therapists use. Working with tio patients is described as “interesting” and “fascinating” (Bloomfield, 1989), bu “nourishing” (Thorne, 1989), “meaningful” and “stimulating” (Heppner, tri 1989), “exciting” (Fransella, 1989), and “sustaining” (Street, 1989). Some is consider it a “privilege” (Mahoney, 1989; Chaplin, 1989). It clearly repre- rD sents a part of life which has serious personal meaning and value and which fo therapists would be most reluctant to give up (Fransella, 1989). ot N Despite good intentions and commitment to your work, making sense of d. the cacophony of “latest” developments, let alone applying them in your prac- ve tice, may feel overwhelming. Every day, it seems, there are new fully manual- er ized treatments hot off the press, promising evidence-based change and es R increased effectiveness with this or that disorder. In your day-to-day work with s clients, however, it is never so black-and-white. It is often difficult to even ht ig know if you’re achieving the desired results—or worse, you might realize that R you’re not reaching a particular client but have no idea why and no clue what ll .A to do about it. Even if your overall success rates are good, the accumulation of n unfruitful encounters over time can weigh on you and erode the aspirations io that led you to become a therapist. You read as much as you can, you try new t ia oc approaches, but despite all the hard work you feel as though you’re missing ss something—some, if not many, clients still do not respond to your best efforts. lA How can you achieve better results? In short: how can you become a better ca therapist? gi This book intends to help you answer your calling and remember why lo ho you became a therapist in the first place. It is not about learning the latest and yc greatest miracle method, or a never-before-available way to unravel the mys- Ps teries of the human psyche, or the most recent breakthrough in brain neuro- an chemistry. No husky voiceover will declare a winner of the battle of the ic psychotherapy brands or add yet another fashion to the therapy boutique of er techniques. You have already been there and done that. It is also not about Am becoming “accountable” for the sake of funding sources or to justify your exis- ht tence via showing “proof of value” or “return on investment.” Rather, this rig book is about you—this time it’s personal, from one therapist to another. It’s yop about becoming a better therapist because you got into this business to helpC people—you want to make a meaningful difference in as many lives as possi- ble. Being a therapist is more than a way to make a living to you. Becoming a better one is what you are about. SO YOU WANT TO BE A BETTER THERAPIST 7 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • THE GOOD, THE BAD, AND THE UGLY To exchange one orthodoxy for another is not necessarily an advance. The enemy is the gramophone mind, whether or not one agrees with the record that is being played at the moment. —George Orwell n. The good news is that the efficacy of psychotherapy is very good—the tio bu average treated person is better off than about 80% of the untreated sample tri (Duncan, Miller, Wampold, & Hubble, 2010), translating to an effect size (ES) is of about 0.8.2 Moreover, these substantial benefits apparently extend from rD the laboratory to everyday practice. For example, a real-world study in the fo UK (Stiles, Barkham, Twigg, Mellor-Clark, & Cooper, 2006) comparing ot cognitive–behavioral therapy (CBT), psychodynamic therapy (PDT), and N d. person-centered therapy (PCT) as routinely practiced reported a pre–post ve ES of around 1.30. In short, there is a lot to feel proud about our profession: er psychotherapy works. es But there’s more to the story. The bad news is twofold: First, dropouts are R a significant problem in the delivery of mental health and substance abuse ser- s ht vices, averaging at least 47% (Wierzbicki & Pekarik, 1993). When dropouts are ig considered, a hard rain falls on psychotherapy’s efficacy parade, both in random- R ll ized clinical trials (RCT) and in clinical settings. Second, despite the fact that .A the general efficacy is consistently good, not everyone benefits. Hansen, n io Lambert, and Foreman (2002), using a national database of over 6000 clients, t ia reported a sobering picture of routine clinical care in which only 20% of clients oc improved as compared to the 57–67% rates typical of RCTs. Whichever rate is ss accepted as more representative of actual practice, the fact remains that a sub- lA stantial portion of clients go home without help. ca And the ugly: Explaining part of the volatile results, variability among gi lo therapists is the rule rather than the exception. Not surprisingly, although rarely ho discussed, some therapists are much better at securing positive results than yc others. In fact, therapist effectiveness ranges from 20–70%! Moreover, even Ps very effective clinicians seem to be poor at identifying deteriorating clients. an Hannan et al. (2005) compared therapist predictions of client deterioration to ic actuarial methods. Though therapists were aware of the study’s purpose, famil- er Am iar with the outcome measure used, and informed that the base rate was likely to be 8%, they accurately predicted deterioration in only 1 out of 550 cases; ht yrigop 2Effect size (ES) refers to the magnitude of change attributable to treatment, compared to an untreatedC group. The ES most associated with psychotherapy is 0.8 standard deviations above the mean of the untreated group. An ES of 1.0 indicates that the mean of the treated group falls at approximately the 84th percentile of the untreated one. Consequently, the average treated person is better off than approximately 80% of those without the benefit of treatment. 8 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • psychotherapists did not identify 39 out of the 40 clients who deteriorated. In contrast, the actuarial method correctly predicted 36 of the 40. So, despite the overall efficacy and effectiveness of psychotherapy, drop- outs are a substantial problem, many clients do not benefit, and therapists vary significantly in effectiveness and are poor judges of client deterioration. Most of us provide an invaluable service to our clients, but sadly most of us don’t n. know how effective we really are—we don’t know who will drop out or who will tio ultimately not benefit or even deteriorate. Do you know how effective you are? bu With dropouts considered, how many of your clients leave your office absent of tri is benefit? Which clients in your practice now are at risk for dropout or negative rD outcome? fo What is the solution to these problems? Sometimes our altruistic desire ot to be helpful hoodwinks us into believing that if we were just smart enough or N trained correctly, clients would not remain inured to our best efforts—if we d. ve found the Holy Grail, that special model or technique, we could once and for er all defeat the psychic dragons that terrorize clients. We come by this belief es honestly—we hear it all the time, constantly reinforced on nearly all fronts. R The warring factions carry on the struggle for alpha dogma status in the psy- s ht chotherapy pack and claims of “miracle cures better than the rest” continue ig unabated. In a recent article in the Psychotherapy Networker, the most read R publication by mental health professionals, several approaches were identified ll .A as significant advancements (Lebow, 2007, p. 46). The article swooned with n praise (e.g., “impressive outcomes, outcomes light–years ahead”)—the subtext tio ia is that if we don’t avail ourselves of these approaches we are doing our clients oc a reprehensible disservice—but left out a vital fact: None of the heralded mod- ss els have reliably demonstrated superiority to any other systematically applied lA psychotherapy. ca This, of course, is the famous dodo bird verdict (“All have won and all must gi have prizes”), taken from the classic Lewis Carroll (1865/1962) tale, Alice in lo ho Wonderland, first invoked by Saul Rosenzweig way back in 1936 to illustrate yc the equivalence of outcome among approaches (see Duncan, 2010). The Ps dodo verdict is the most replicated finding in the psychological literature— an encompassing a broad array of research designs, problems, populations, and ic clinical settings. For example, the study mentioned previously (Stiles et al., er 2006) comparing CBT, PDT, and PCT as routinely practiced, once again Am found no differences among the approaches. ht Perhaps a more controversial illustration is provided by the treatments rig for the diagnosis du jour, posttraumatic stress disorder (PTSD). CBT has been yop demonstrated to be effective and is widely believed to be the treatment ofC choice, but several approaches with diverse rationales and methods have also been shown to be effective: eye-movement desensitization and reprocessing, cognitive therapy without exposure, hypnotherapy, psychodynamic therapy, SO YOU WANT TO BE A BETTER THERAPIST 9 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • and present-centered therapy. A recent meta-analysis comparing these treat- ments found all of them about equally effective (Benish, Imel, & Wampold, 2007). What is remarkable here is the diversity of methods that achieve about the same results. Two of the treatments, cognitive therapy without expo- sure and present-centered therapy, were designed to exclude any therapeutic actions that might involve exposure (clients were not allowed to discuss their n. traumas because that invoked imaginal exposure). Despite the presumed tio extraordinary benefits of exposure for PTSD, the two treatments without it, or bu in which it was incidental (psychodynamic), were just as effective (Benish tri is et al., 2007). This study only confirms that the competition among the more rD than 250 therapeutic schools remains little more than the competition among fo aspirin, Advil, and Tylenol. All of them relieve pain and work better than no ot treatment at all. As the dodo wisely judged, all deserve prizes because none N stands above the rest. When it is all said and done, model differences only d. ve amount to an ES of about 0.2, an underwhelming 1% of the overall variance er of outcome (Wampold, 2001). es Unfortunately, the mountain of evidence researchers have amassed has R had little impact on the graduate or postgraduate training of mental health s ht professionals, or sadly, on professional attitudes. We spend thousands of dol- ig lars on workshops, conferences, and books to learn highly publicized methods R of treatment. Unfortunately, instead of feeling hopeful or validated and expe- ll .A riencing the promised “outcomes light–years ahead,” we often wind up feeling n demoralized. Why didn’t the powerful sword slay the dragon of misery of the tio ia client in my office now? The answer all too often is to blame ourselves—we oc are just not measuring up. The Holy Grail seems just out of reach. ss Don’t get me wrong. There is nothing wrong with learning about mod- lA els and techniques—in fact, it is a good thing as I’ll discuss below and through- ca out the book—but becoming beholden to one isn’t, nor is believing that gi salvation will come from them. They are indeed false gods. First, given the lo ho robust findings supporting the dodo verdict, it is important to keep in mind yc that the much ballyhooed models have only shown themselves to be better Ps than sham treatments or no treatment at all, which is not exactly news to write an home to mom about. Think about it. What if one of your friends went out on ic a date with a new person, and when you asked about the guy, your friend er replied, “He was better than nothing—he was unequivocally better than Am watching TV or washing my hair.” (Or, if your friend was a researcher: “. . . he ht was significantly better, at a 95% confidence level, than watching TV or wash- rig ing my hair.”) How impressed would you be? yop And second, the idea that change primarily emanates from the model orC techniques you wield is a siren call destined to smash you against the jagged rocks of ineffective therapy. That therapists might possess the psychological equivalent of a “pill” for emotional distress resonates strongly with many, and 10 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • is nothing if not seductive as it teases our desires to be helpful. A treatment for a specific “disorder,” from this perspective, is like a silver bullet, potent and transferable from research setting to clinical practice. Any therapist need only to load the silver bullet into any psychotherapy revolver and shoot the psychic werewolf stalking the client. In its most unfortunate interpretation, clients are reduced to a diagnosis and therapists are defined by a treatment technology— n. both interchangeable and insignificant to the procedure at hand. This prod- tio uct view of psychotherapy is most empirically vacuous because the treatment bu itself accounts for so little of outcome variance, while the client and the tri is therapist—and their relationship—account for so much more. rD Fear is also a potent motivator for the ongoing search for the Holy Grail. fo Going well beyond subtext, we are told that not administering the “right” ot treatment is unethical (Chambless & Crits-Christoph, 2006) and even “pros- N ecutable”! A New York Times article reported: d. ve Using vague, unstandardized methods to assist troubled clients ‘should er be prosecutable’ in some cases, said Dr. Marsha Linehan . . . (Carey, es 2005, p. 2) R s Given the relative contribution of model and technique to change and ht ig the lack of demonstrated superiority of dialectical behavior therapy or any other R approach, perhaps it should be “prosecutable” to make such bold statements. ll .A In truth, we are easily smitten by the lure of flashy techniques and “out- n comes light-years ahead.” Amid explanations and remedies aplenty, therapists tio courageously continue the search for designer explanations and brand name ia oc miracles—disconnected from the power for change that resides in the pairing ss of two unique persons, the application of strategies that resonate with both, and lA the impact of a quality partnership. Despite our generally good results and her- ca culean efforts to master the right approach, we continue to observe that clients gi drop out or, even worse, continue without benefit. lo ho yc To the Rescue: Practice-Based Evidence Ps an There is a practical clinical solution to these everyday pitfalls called ic “practice-based evidence” (Barkham et al., 2001; Duncan, Miller, & Sparks, er 2004). Howard, Moras, Brill, Matinovich, and Lutz (1996) were the first to Am advocate for the systematic evaluation of client response to treatment dur- ht ing the course of therapy, and to recommend that such information be used rig to “determine the appropriateness of the current treatment . . . the need for yop further treatment . . . [and] prompt a clinical consultation for patients whoC [were] not progressing at expected rates” (p. 1063). When this occurs—when client feedback is systematically collected and used to tailor treatment—good things happen. For example, using the Outcome Questionnaire 45.2, feedback SO YOU WANT TO BE A BETTER THERAPIST 11 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • pioneer Michael Lambert has conducted five RCTs and all five demonstrated significant gains for feedback groups over treatment as usual (TAU) for clients at risk for a negative outcome. Twenty-two percent of TAU at-risk cases reached reliable improvement and clinically significant change, compared with 33% for feedback to therapist groups, 39% for feedback to therapists and clients, and 45% when feedback was supplemented with support tools such n. as measures of the alliance (Lambert, 2010). The addition of client feedback tio alone, without new techniques or models of treatment and leaving therapists bu to practice as they saw fit, enabled over two times the amount of at-risk clients tri is to benefit from psychotherapy. Think of that advantage in your practice. rD Consider the pool of clients in your practice right now who are not benefiting. fo Systematic feedback could allow you to recapture good outcomes with many ot of those clients who would otherwise not benefit. N Continuous client feedback individualizes psychotherapy based on treat- d. ve ment response, provides an early warning system that identifies at-risk clients er thereby preventing dropouts and negative outcomes, and suggests a tried and es true solution to the problem of therapist variability, namely, that feedback R necessarily improves performance and quickens the pace of your development. s ht In truth, practice-based evidence can make you a better therapist—it helps you ig get in the zone of effective psychotherapy.3 R ll n .A GETTING IN THE ZONE tio ia oc To follow knowledge like a sinking star, ss Beyond the upmost bound of human thought . . . lA To strive, to seek, to find, and not to yield. ca —Tennyson gi In a remarkable study, veteran researchers David Orlinsky and Helge lo ho Rønnestad (2005) took an in-depth look at therapists’ experience of their yc work and professional growth. Over a 15-year period, they collected richly Ps detailed reports from nearly 5,000 psychotherapists of all career levels, pro- an fessions, and theoretical orientations from over a dozen countries. From their ic analyses of many specific aspects of therapeutic work, two independent modes er of therapist participation were identified: Am Healing Involvement reflects a mode of participation in which therapists ht experience themselves as personally committed and affirming to patients, yrigop 3The rationale is compelling for securing client feedback. But before this understanding of how feedbackC could address psychotherapy’s pitfalls, before the randomized clinical trials demonstrating the power of feedback, and before the validation studies verified the psychometrics of the measures and that the process might be viable, there was a desire to give clients a voice in their own care, to bring them into the inner circle of decision making. 12 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • engaging at a high level of basic empathic and communication skills, con- scious of Flow-type feelings during sessions, having a sense of efficacy in general, and dealing constructively with difficulties if problems in treat- ment arose. By contrast, Stressful Involvement is a pattern of therapist expe- rience characterized by frequent difficulties in practice, unconstructive efforts to deal with those difficulties by avoiding therapeutic engagement, n. and feelings of boredom and anxiety during sessions. (p. 162) tio An Effective Practice, according to the researchers, is characterized by much bu Healing Involvement and little Stressful Involvement. Healing Involvement tri is represents us at our best—the way we want to be with our clients. Think of it rD as being “in the zone,” akin to how athletes describe their experience when fo their performance is optimal. ot Elite athletes talk a lot about being in the zone, that magical place where N mind and body work in perfect synch, flowing without conscious effort to d. ve athletic nirvana. Perhaps the best theoretical explanation of the zone comes er from Mihaly Csikszentmihalyi in his book Flow: The Psychology of Optimal es Experience. Flow is a state of deep focus that occurs when people engage in R challenging tasks that demand intense concentration and commitment— s ht when skill level is perfectly balanced to the challenge level of a task that has ig clear goals and provides immediate feedback (Csikszentmihalyi, 1990). R All kinds of activity can trigger flow. People talk of “losing track of time” ll .A when they are gardening, playing softball, cooking an elaborate meal, or con- n ducting psychotherapy. We’ve all had the experience where we’ve become so tio ia completely absorbed in our work that time flies by, the outside world is a mil- oc lion miles away, and our talents flow freely—those times when our immersion ss into our client’s story is so complete, our attunement so sharp, and the path lA required for change eminently accessible. These episodes can be deeply grat- ca ifying, and some of our best work comes out of them. Sometimes you feel the gi texture of your connection with clients, an intimate space where you both lo ho know that there is something very good about this conversation, something yc that inspires hope. This is healing involvement. So, what causes this and, more Ps important, how can we make it happen more often? an Here is where the research of Orlinsky and Rønnestad is priceless. Their ic extensive investigation identified three sources of healing involvement, a ther- er apist’s experience of being in the zone: First is the therapist’s sense of cumula- Am tive career development—improvement in clinical skills, increasing mastery, and ht gradual surpassing of past limitations. Therapists like to think of themselves as rig getting better, over time, at what they do. Eighty-six percent of the therapists, yop regardless of career level, reported that they were “highly motivated” to pur-C sue professional development. This is truly remarkable. There is no other pro- fession, as a group, more committed to getting better at what they do. Most professions, it appears, believe that one arrives at some degree of competency SO YOU WANT TO BE A BETTER THERAPIST 13 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • at some point. Not therapists. They want to continue to get better throughout their careers. Second, as implied, another important influence on healing involvement is the therapist’s sense of theoretical breadth. Orlinsky and Rønnestad suggest that understanding clients from a variety of conceptual contexts enhances the therapist’s adaptive flexibility in responding to the challenges of clinical work. n. Indeed, broad-spectrum integrative-eclectic practitioners were more likely to tio experience healing involvement. This suggests that therapists who are in the bu zone more do not marry any model, but rather remain theoretically promiscu- tri is ous. Again this makes sense. Possessing a range of understandings of client rD problems as well as possible methods to address them allows therapists to expe- fo rience healing involvement more often with more clients—a suggestion in ot line with what the psychotherapy integration movement has been telling us N all along (e.g., Norcross & Goldfried, 2005; Stricker & Gold, 2006). d. ve The third and by far the most powerful influence on being in the zone is er the therapist’s sense of currently experienced growth. Therapists like to think of es themselves as developing now. Your ongoing experience of professional devel- R opment is therefore critical to becoming a better therapist. In a sense we con- s ht tinually ask ourselves, “What have you done for me lately?” Therapists with ig the highest levels of current growth showed the highest levels of healing R involvement. Orlinsky and Rønnestad suggest that the experience of current ll .A growth translates to positive work morale and energizes therapists to apply n their skills on behalf of clients. In addition, currently experienced growth fos- tio ia ters a process of continual professional reflection (Rønnestad & Skovholt, oc 1991), a bonus that keeps therapists motivated to seek out specialty training, ss supervision, personal therapy, or what-have-you to keep the pedal down on lA the developmental process. It makes sense, when you think about it, that if we ca see our work as a calling and a means to personal meaning and satisfaction, gi then our view of our own growth as a therapist would be quite important to lo ho us—so much so that we might do well to keep a finger on the pulse of our yc development at all times. Ps How do therapists attain a sense of currently experienced growth? an According to Orlinsky and Rønnestad (2005), the most widely endorsed ic positive influence was practical–experiential learning through direct clini- er cal work—by the quality of therapists’ experiences in working with clients. Am Not workshops and books trumpeting the latest and greatest. Rather, almost ht 97% of therapists reported that learning from their experiences with rig clients was a significant influence on their development. A full 84% rated yop this influence as high. In truth, beyond cliché, therapists do believe thatC clients are the best teachers. Our sense of currently experienced growth depends on these frontline lessons, which in turn, is a primary source of healing involvement. 14 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • How does all this relate to client feedback? Tracking client responses to therapy provides an accessible route to being in the zone, addressing all three sources identified by Orlinsky and Rønnestad. First, collection of client feed- back allows you to monitor your outcomes and plot your career development, so you will know about your effectiveness and whether you are improving. Moreover, charting your outcomes not only permits a more systematic process n. of planning and implementing strategies to improve your effectiveness, but it tio also permits your evaluation of the strategies and whether or not your time bu tri might be better spent elsewhere. Second, tailoring your approach based on is client feedback about benefit and the fit of the services will lead you to theo- rD retical breadth as you expand your repertoire to serve more clients. Soliciting fo client feedback enhances your ability to be tuned to client preferences and ot encourages your flexibility to try out new ideas in search of what resonates with N d. clients—opening you to a range of theoretical explanations and attending ve methods. Finally, securing client feedback seats you in the front of the class so er you can readily see and hear the lessons of the day—to experience your cur- es rently experienced growth. Later, I’ll show how client feedback or practice-based R evidence encourages your continual professional reflection with each client, s ht thereby increasing your learning potential exponentially. Client feedback is ig R the compass that provides direction out of the wilderness of negative out- ll comes and average therapy—taking the notion of clients as the best teachers .A of psychotherapy well beyond cliché, significantly accelerating your develop- n io ment as a therapist, and helping you become a better one. t ia oc ss lA CLIENTS ARE THE BEST TEACHERS ca gi Of all tyrannies, a tyranny sincerely exercised for the good of its victims lo may be the most oppressive. ho —C. S. Lewis yc Ps Dan Ariely, in his book Predictably Irrational (2008; see also http://www. an youtube.com/watch?v=8I6wa3eK6zQ), tells a horrendous story of an explo- ic sion that left him with 70% of his body covered with third-degree burns. er His treatment included a much-dreaded daily removal of his bandages. In Am the absence of skin, the bandages were attached to raw bleeding flesh and ht their removal was both harrowing and excruciatingly painful. The nurses rig removed the bandages as fast as possible, quickly ripping them off one by yop one. Believing that a slower pace would be less painful, Ariely repeatedlyC asked the nurses to slow down the removal process. The nurses, however, asserted that finishing as fast as possible was the best approach, and contin- ued to do so. SO YOU WANT TO BE A BETTER THERAPIST 15 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • This ordeal miraculously inspired Ariely to research the experience of pain as well as other phenomena. His investigation of pain demonstrated that a slow and less intense experience of pain over longer periods was far easier to tolerate than more intense pain over shorter time frames. Consider this story and its relevance to psychotherapy. It is noteworthy that the nurses dis- regarded Ariely’s response to their removal methods—his experience of his n. own pain did not hold much weight! Ignoring his response as well as his plead- tio ings to slow down was not because the nurses were evil or had any malevolent bu intentions—in fact, Ariely reports that he grew to love the nurses and believed tri is that they loved him as well. Rather, the nurses assumed they knew more about rD his pain than he did and went full steam ahead for his own good! He also later fo learned that the nurses considered it easier for them to remove the dressings ot quickly. Clinical lore about the rapid removal of bandages, as well as what was N convenient for the nurses, prevailed over Ariely’s experience of his own pain. d. ve When services are provided without intimate connection to those er receiving them and to their responses and preferences, clients become card- es board cutouts, the object of our professional deliberations and subject to our R whims. Valuing clients as credible sources of their own experiences allows us s ht to critically examine our assumptions and practices—to support what is work- ig ing and challenge what is not—and allows clients to teach us how we can be R the most effective with them. ll .A The idea that clients are the best teachers has a long and rich history in n psychotherapy. Indeed, it is difficult if not impossible to routinely sit with tio ia people in the throes of emotional or situational disaster, then witness their oc journey to a better place, and not be changed by that experience. Some have ss written about the reversal of roles that can happen between therapists and lA clients, where therapists emerge as the main beneficiary of the therapeutic ca process; others have written about the profound lessons that clients teach us gi about life; still others have pointed to even a higher learning, an experience lo ho that was personally and professionally transformational. There are also yc compendiums of such lessons. Veteran psychotherapy researcher Marvin Ps Goldfried (2001), for example, compiled a series of clinical events that an resulted in conceptual revisions among well-known theorists. In a book about ic the changes incurred in experienced therapists lives (Kahn & Fromm, 2001), er Spiegel (2001) notes the personal changes he has made because of his work Am with cancer patients—their struggles regarding impending death inspired him ht to live his own life more intensely. In their compelling book, The Client Who rig Changed Me, prolific authors Jeffrey Kottler and Jon Carlson (2005) focused yop their efforts on the really big changes that therapists experience as a directC result of their work with clients. Clients provide the opportunity for constant learning about the nature of the human condition and about different cultures and worldviews, as well 16 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • as the myriad ways by which people transcend adversity and cope with the unthinkable. With each session under our belt, we become more knowledge- able about people and worldly in our views. While these types of hard-learned lessons—the everyday and the transformational—are noteworthy (and this book contains client stories influential in my development as a therapist), the notion that “the client is the best teacher” is invoked here in a different way. n. It carries a far more literal meaning. Continuous client feedback permits a tio practical process in which clients proactively shape our behavior until we get bu it right with them or we move them on to someone else. tri is Acquiring formal feedback enables a transparent conversation unlike rD what most of us have ever experienced. With a collaborative focus on the ben- fo efit and fit of psychotherapy, clients can teach us how to do more effective work, ot specifically, on a session-by-session, and even within-session, basis. Beyond les- N sons about life or about the work of psychotherapy in general, a culture of con- d. ve tinuous client feedback keeps our utmost attention on the here and now with er this client in this session. Clients teach us with their responses—whether or not es they are benefiting and whether or not our service is a good fit for them—as well R as with their reactions and reflections about the next step. In short, practice- s ht based evidence enables your clients to teach you how to do better work, espe- ig cially those who are not responding to your therapeutic business as usual. R ll n .A io WHAT WORKS IN THERAPY: GUIDELINES FROM RESEARCH t ia oc Whoever acquires knowledge and does not practice it resembles him [sic] ss who ploughs his land and leaves it unsown. lA —Sa’di, Gulistan ca gi A story illustrates the sentiments that many practitioners feel about lo ho research. Two researchers were attending their annual conference. Although yc enjoying the proceedings, they decided to find some diversion to combat the Ps tedium of sitting all day and absorbing vast amounts of information. They set- an tled on a hot-air balloon ride and were quite enjoying themselves until a mys- ic terious fog rolled in. Hopelessly lost, they drifted for hours until, finally, a er clearing in the fog appeared and they saw a man standing in an open field. Am Joyfully, they yelled down at the man, “Where are we?” The man looked at ht them, and then down at the ground, before turning a full 360 degrees to sur- rig vey his surroundings. Finally, after scratching his beard and what seemed to yop be several moments of facial contortions reflecting deep concentration, theC man looked up and said, “You are above my farm.” The first researcher looked at the second researcher and said, “That man is a researcher—he is a scientist!” To which the second researcher replied, SO YOU WANT TO BE A BETTER THERAPIST 17 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • “Are you crazy, man? He is a simple farmer!” “No,” answered the first researcher emphatically, “that man is a researcher and there are three facts that support my assertion: First what he said was absolutely 100% accurate; second, he systematically addressed our question through an examination of all of the empirical evidence at his disposal, and then carefully deliberated before deliv- ering his conclusion; and finally, the third reason I know he is a researcher is n. that what he told us is absolutely useless to our predicament.” In this book, I tio only present research that directly informs my psychotherapy practice and that bu will be useful to your predicament. If it doesn’t pass that test, you will not read tri is it here. rD The common factors—what works in therapy—have a storied history fo that started with Rosenzweig’s (1936) classic article “Implicit Common ot Factors in Diverse Forms of Psychotherapy.” In addition to the original invo- N cation of the dodo bird and seminal explication of the common factors of d. ve change, Rosenzweig also provided the best explanation for the common fac- er tors, still used today, namely, that given that all approaches achieve roughly es similar results, there must be pantheoretical factors accounting for the R observed changes beyond the presumed differences among schools (Duncan, s 2010). ht ig Jerome Frank (Frank, 1961, 1973; Frank & Frank, 1991) advanced the R idea that psychotherapy orientations (and other forms of healing) are equiva- ll .A lent in their effectiveness because of factors shared by all: (a) a healing setting; n (b) a rationale, myth, or conceptual framework that provides an explanation tio ia for the client’s complaint and a method for resolving it; (c) an emotionally oc charged, confiding relationship with a helping person; and (d) a ritual or pro- ss cedure that requires involvement of both the healer and client to bring about lA “cure” or resolution. Frank’s work is particularly helpful, as noted below, in ca understanding the role of model and technique as the vehicle for delivering gi the other factors. lo ho Several others have identified these elements found in all therapies, but yc Brigham Young University’s Michael Lambert deserves special mention. After Ps an extensive analysis of decades of outcome research, Lambert (1986) identi- an fied four factors—and their estimated percentages of outcome variance—as ic the principal elements accounting for improvement: extratherapeutic (client) er variables (40%); relationship factors (30%); hope, expectancy, and placebo Am (15%); and model/technique (15%) (see Figure 1.2). Although these factors ht are not derived from a statistical analysis, he suggested that they embody what rig studies indicated about treatment outcome. Lambert’s portrayal of the com- yop mon factors bravely differentiated factors according to their relative contribu-C tion to outcome, opening a new vista of understanding models and their proportional importance to success—a bold challenge to the typical reverence many researchers and therapists feel toward their preferred models. 18 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • C l i e n t /E xtratherapeuti c 40. 0% n. Re la t ions h i p tio Model /Techni ques 3 0 .0 % bu 15. 0% tri is 15. 0% rD Pl ac e b o , H ope, and E xpectancy fo ot Figure 1.2. Lambert’s Common Factors. From “The Empirical Case for the Common N Factors in Therapy: Quantitative Findings,” by T. P. Asay and M. J. Lambert, 1999, d. in M. A. Hubble, B. L. Duncan, and S. D. Miller (Eds.), The Heart and Soul of ve Change: What Works in Therapy, pp. 33–56. Copyright 1999 by the American Psychological Association. Adapted with permission. er es R Inspired by Lambert’s proposal and the integration movement, my col- s ht leagues and I (Duncan & Moynihan, 1994; Duncan, Solovey, & Rusk, 1992) ig proposed a “client directed” perspective to apply the common factors based R on their differential impact on outcome. “Client directed” spoke to the power ll .A of extratherapeutic (or client) factors as well as the privilege that should be n afforded to client ideas, view of the alliance, and preferences about interven- tio ia tion; intervention effectiveness was described as dependent on rallying client oc resources and as a tangible expression of the quality of the alliance. I have ss been writing about my attempts to operationalize the factors ever since (e.g., lA Duncan et al., 2010; Sparks & Duncan, 2010). The common factors help ca us take a step back and get a big-picture view of what really works, suggest- gi ing that we spend our time in therapy commensurate to each element’s dif- lo ho ferential impact on outcome. yc Recent findings from meta-analytic studies as well as more attention to Ps therapist variance paint a more complicated but satisfying representation of an the different factors, their effects, and their relationship to each other. The ic “pie chart” view of the common factors incorrectly implies that the proportion er of outcome attributable to each was static and could be added up to 100% of Am therapy effects. This suggested that the factors were discrete elements and ht could be distilled into a treatment model, techniques created, and then admin- rig istered to the client. Any such formulaic application across clients, however, yop merely leads to the creation of another model. On this point, the jury hasC deliberated and the verdict has been rendered; whether common factors or not, model differences ultimately matter little in terms of outcome. In truth, the factors are interdependent, fluid, dynamic, and dependent on who the SO YOU WANT TO BE A BETTER THERAPIST 19 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • players are and what their interactions are like. Five factors comprise this perspective: client, therapist, alliance, the model/technique delivered, and feedback. Extratherapeutic/Client Factors n. To understand the common factors, it is first necessary to separate the tio variance due to psychotherapy from that attributed to extratherapeutic fac- bu tors, those variables incidental to the treatment model, idiosyncratic to the tri is specific client, and part of the client’s life circumstances that aid in recovery rD despite participation in therapy (Asay & Lambert, 1999)—everything about fo the client that has nothing to do with us. ot Recall the old public service message that showed a skillet and said, “This N is your brain,” and then showed an egg being broken and starting to fry, while d. ve the voiceover says, “This is your brain on drugs.” Think of Lambert’s pie chart er illustration as the common factors. Think of Figure 1.3 as the common factors es on drugs. R The proportion of outcome attributable to client factors is represented s ht by the circle on the left. The variance accounted for by treatment is depicted ig R ll .A Client/Extratherapeutic Factors (87%) n tio ia oc Feedback Effects ss 15-31% lA Alliance Effects ca Treatment Effects 38-54% gi 13% lo ho yc Model/Technique Ps 8% an ic er Am Model/Technique Delivered: ht Therapist Effects Expectancy/Allegiance rig 46-69% Rationale/Ritual (General y Effects)op 30-?%C Figure 1.3. The Evolution of Common Factors with the Proposed Feedback Factor. 20 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • by the small circle nested within client factors (at the lower right side). Even a casual inspection reveals the disproportionate influence of what the client brings to therapy. Client factors, including unexplained and error variance account for 87% of the variance of change, leaving 13% of the variance accounted for by psychotherapy (Wampold, 2001). These extratherapeutic aspects consist of client strengths, struggles, motivations, distress, supportive n. elements in the environment, and even chance events. As examples, persis- tio tence, faith, a supportive grandmother, depression, membership in a religious bu community, divorce, sense of personal responsibility, a new job, a good day at tri is the track, a crisis successfully managed—all may be included. These elements rD are the most powerful of the common factors in therapy; the client is the fo engine of change (Bohart & Tallman, 2010). ot In the absence of compelling evidence for any specific variables that cut N across clients to predict outcome or account for the unexplained variance, d. ve this most potent source remains largely uncharted. Client factors cannot be er generalized because they differ with each client. These unpredictable differ- es ences can only emerge one client at a time, one alliance at a time, one ther- R apist at a time, and one treatment at a time. Although specific treatments do s ht not seem to have much in the way of unique ingredients, the data seem to ig suggest that clients do. R ll But we do know something for sure: If we don’t recruit these idiosyn- .A cratic contributions to outcome in service of client goals, we are inclined n io to fail. Indeed, in a comprehensive review of 50 years of literature for the t ia 5th edition of the Handbook of Psychotherapy and Behavior Change, Orlinsky, oc Rønnestad, and Willutzki (2004) indicate, “the quality of the patient’s ss participation . . . [emerges] as the most important determinant of outcome” lA (p. 324; emphasis added). ca gi Bottom Line: Becoming a better therapist depends on rallying clients and their lo resources to the cause. Practice-based evidence sets the context for client par- ho ticipation in the monitoring of therapy outcome and fit. yc Ps Figure 1.3 also illustrates the second step in understanding the common fac- an tors. The second, larger circle in the center depicts the overlapping elements that ic form the 13% of variance attributable to treatment. Visually, the relationship er among the common factors, as opposed to a static pie-chart depicting discreet ele- Am ments adding to a total of 100%, is more accurately represented with a Venn ht diagram, using overlapping circles and shading to demonstrate mutual and inter- rig dependent action. The factors, in effect, act in concert and cannot be separated yop into disembodied parts (Duncan et al., 1992).C To exemplify the various factors and their attending portions of the variance, the tried and true Treatment of Depression Collaborative Research SO YOU WANT TO BE A BETTER THERAPIST 21 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • Program (TDCRP) (Elkin et al., 1989) will be enlisted. The TDCRP randomly assigned 250 depressed participants to four different conditions: CBT, interper- sonal therapy (IPT), antidepressants plus clinical management (IMI), and a pill placebo plus clinical management. The four conditions—including placebo— achieved about the same results, although both IPT and IMI surpassed placebo (but not the other treatments) on the recovery criterion (yet another example n. of the dodo verdict). Although the TDCRP is now over 20 years old, the data tio continue to be analyzed and relevant, as we will see below. bu tri is Therapist Effects rD fo Therapist effects represent the amount of variance attributable not to the ot model wielded, but rather to who the therapist is. Indeed, therapist factors have N emerged as potent and predictive aspects of therapeutic services, accounting d. ve for more of the variance of outcome than any treatment provided, second only er to what the client brings (Wampold & Brown, 2005). You definitely matter to es outcome. This is why attention to your development and your sense of heal- R ing involvement is important. s ht Depending on the study, therapist effects range from 6–9% of the over- ig all variance of change (Beutler et al., 2004; Crits-Christoph et al., 1991; R Project MATCH, 1998) or 46–69% of the variance attributed to treatment.4 ll .A Putting this into perspective, the amount of variance attributed to therapist n factors is about six to nine times more than that of model differences. In the io t TDCRP, 8% of the variance in the outcomes within each treatment was due ia oc to therapists (Kim, Wampold, & Bolt, 2006). The psychiatrists in the study ss highlight this finding—the clients receiving sugar pills from the top third most lA effective psychiatrists did better than the clients taking antidepressants from ca the bottom third least effective psychiatrists. gi What accounts for the variability? Although we know for sure that some lo therapists are better than others, there is not a lot of research about what dis- ho yc tinguishes the best from the rest. But there is one good possibility and one Ps no-brainer. Gassman and Grawe (2006) conducted minute-by-minute analy- ses of 120 sessions involving 30 clients treated for a range of psychological an problems. They found that unsuccessful therapists focused on problems while ic er neglecting client strengths. When the unsuccessful therapists did focus on Am clients’ strengths, they did so more at the end of a therapy session. Successful therapists focused on their clients’ strengths from the very start. And we know ht rig that the alliance accounts for the lion’s share of therapist variability. Two y recent studies (Baldwin, Wampold, & Imel, 2007; Owen, Anker, Duncan, &opC 4The percentages are best viewed as a defensible way to understand outcome variance, but not as repre- senting any ultimate truths. Because of the overlap among the common factors, the percentages for the separate factors will not add to 100%. 22 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • Sparks, 2010) found that therapists who generally form better alliances also had better outcomes. In fact, Owen et al. (2010) found that a whopping 40% of the variability in outcome due to therapists was accounted for by the client’s alliance rating in the last session. Such findings suggest that the alliance may represent the best arena for influencing therapist effects. Bottom Line: Therapist differences loom large and are related to the ability n. tio to mobilize client resources and participation, as well as form strong alliances. bu Practice-based evidence engages clients by design in a partnership that increases tri client participation and resource activation, while not leaving the alliance is to chance. rD fo ot The Alliance N d. Researchers repeatedly find that a positive alliance—an interpersonal ve er partnership between the client and therapist to achieve the client’s goals es (Bordin, 1979)—is one of the best predictors of outcome (Horvath & Bedi, R 2002; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). The s ht amount of variance attributed to the alliance ranges from 5% to 7% of overall ig variance or 38% to 54% of the variance accounted for by treatment. Putting R this into perspective, the amount of change attributable to the alliance is about ll .A five to seven times that of specific model or technique. Krupnick et al. (1996) n analyzed data from the TDCRP and found that the alliance, from the client’s tio perspective, was predictive of success for all conditions; the treatment model ia oc was not. Mean alliance scores explained 21% of the variance (Wampold, ss 2001). (Keep in mind that treatment accounts for, on average, 13% of the vari- lA ance.) The alliance in the TDCRP explained more of the variance by itself, ca illustrating how the percentages are not fixed and depend on the particular gi context of client, therapist, alliance, and treatment model. Finally, a recent lo ho study looking at alliances in couple therapy (Anker, Owen, Duncan, & Sparks, yc 2009) found that the alliance predicted outcome after controlling for early Ps change, suggesting that the alliance has causal impact beyond client experi- an ence of improvement. ic Consider the dimension of healing involvement in light of our alliance er discussion. Based on their extensive study of therapists, as well as their career- Am long analyses of process–outcome relationships, Orlinsky and Rønnestad ht (2005) suggest: rig There is, in fact, a striking similarity between the depiction of effec- yop tive therapeutic process based on 50 years of process-outcome researchC and the therapeutic work dimension of Healing Involvement. . . . Positive therapeutic outcomes are robustly predicted when therapists are experienced as being personally engaged rather than detached, SO YOU WANT TO BE A BETTER THERAPIST 23 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • collaborative rather than directive, empathic, and warmly affirming. This pattern of relating to patients is the same that therapists experience in Healing Involvement. (pp. 178–179) Bottom Line: The alliance makes significant contributions to psychotherapy outcome and therefore should be actively monitored and tailored to the indi- vidual client. n. tio Model/Technique Delivered: Allegiance and bu Placebo (Expectancy) Factors tri is rD Model/technique factors are the beliefs and procedures unique to any fo given treatment. But these specific effects—the impact of the differences ot among treatments—are very small, only about 1% of the overall variance, or N 8% of that attributable to treatment. But the general effects of delivering a treat- d. ve ment are far more potent. As Jerome Frank (1973) seminally noted, all mod- er els include a rationale or myth, an explanation for the client’s difficulties, and es a procedure or ritual, strategies to follow for resolving them. Models achieve R their effects, in large part, if not completely through the activation of placebo, s ht hope, and expectancy, combined with the therapist’s belief in (allegiance to) ig the treatment administered. As long as a treatment makes sense to, is accepted R by, and fosters the active engagement of the client, the particular approach ll .A used is unimportant. Said another way, therapeutic techniques are placebo- n delivery devices (Kirsch, 2005). tio ia Allegiance and expectancy are two sides of the same coin—the belief by oc both the therapist and the client in the restorative power and credibility of the ss therapy’s rationale and related rituals. When a placebo or technically “inert” lA condition is offered in a manner that fosters positive expectations for improve- ca ment, it reliably produces effects almost as large as a bona fide treatment gi (Baskin, Tierney, Minami, & Wampold, 2003). The TDCRP is again instruc- lo ho tive. First, across all conditions, client expectation of improvement pre- yc dicted outcome (Sotsky et al., 1991). And second, an inspection of the Beck Ps Depression Inventory scores of those who completed the study (see Elkin an et al., 1989) reveals that the placebo plus clinical management condition ic accounted for nearly 93% of the average response to the active treatments. er To punctuate the point about the more powerful general effects, consider Am “present centered therapy” mentioned above as a treatment that works for ht PTSD (see Wampold, 2007, for a full description). Researchers testing the effi- rig cacy of CBT for PTSD wanted a comparison group that contained curative fac- yop tors shared by all treatments (warm, empathic relationship) while excludingC those believed unique to CBT (exposure). This control treatment, present cen- tered therapy (PRCT), contained no treatment rationale and no therapeutic actions. Moreover, to rule out any possibility of exposure, even covert in nature, 24 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • clients were not allowed to talk about the traumatic events that had precipi- tated therapy. PRCT was, of course, found to be less effective than CBT—it wasn’t really a treatment with professed “active” ingredients. However, when later a manual containing a rationale and condition-specific treatment actions was added to facilitate standardization in training and delivery, few differences in efficacy were found between PRCT and CBT in the treatment of PTSD n. (McDonagh et al., 2005). In fact, significantly fewer clients dropped out of tio PRCT than CBT. Thus, when PRCT was made to resemble a bona fide treat- bu ment, that is, it added placebo, expectancy, and allegiance variables, it was not tri is only as effective but also more acceptable than CBT. rD The act of administering treatment—the model/technique delivered5— fo is the vehicle that carries allegiance and placebo effects in addition to the ot specific effects of the given approach. It pays, therefore, to have several N rationales and remedies at your disposal that you believe in, as well as d. ve believing in the possibility of the client’s ideas about change. Placebo fac- er tors are also fueled by a therapist’s belief that change occurs naturally and es almost universally—the human organism, shaped by millennia of evolu- R tion and survival, tends to heal and to find a way even out of the heart of s darkness (Sparks & Duncan, 2010). ht ig Finally, it is important to note that suggesting that specific effects are small R in comparison to general effects and that psychotherapy approaches achieve ll .A about the same results, does not mean that models and techniques are not impor- n tant. On the contrary, a particular orientation or method may be just the ticket tio for a given client. While there is no differential efficacy on aggregate, there are ia oc approaches that are likely better or worse for the client in your office now. ss lA Bottom Line: The specifics of any approach, either unique to the client or to a particular orientation, are not as important as the cogency of the rationale ca and ritual to both the client and the therapist, and, most importantly, as the gi lo client’s response to the delivered treatment. ho yc Ps Feedback Effects an Practice-based evidence will likely become the rage of the next decade— ic er and for good reason: monitoring client-based outcome, when combined with Am feedback to the clinician, significantly increases the effectiveness of services. Lambert (2010) reports that effect sizes for the difference between feedback ht rig and TAU ranges from .34 to .92, unusually large considering that the estimates y of the ES of the difference between empirically supported and comparisonopC 5This term was coined by Bruce Wampold and the idea grew out of a discussion during the preparation of the introductory chapter in The Heart and Soul of Change, but was not included or developed in that chapter. SO YOU WANT TO BE A BETTER THERAPIST 25 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • treatments are about .20. Putting this in perspective, feedback has two to four times the impact of model differences. Although there are several quality feedback systems available (see Lambert, 2010), the feedback process presented in this book is the Partners for Change Outcome Management System (PCOMS) (Duncan et al., 2004; Miller, Duncan, Sorrell, & Brown, 2005). Much of this system’s appeal rests n. on the brevity of the measures and therefore its feasibility for everyday use tio in the demanding schedules of front-line clinicians. It was developed with bu you in mind, because I am one of you. The Outcome Rating Scale (ORS) tri is and the Session Rating Scale (SRS) are both four-item measures designed to rD track outcome and the therapeutic alliance, respectively. PCOMS was based fo on Lambert’s continuous assessment model using the Outcome Question- ot naire 45.2 (Lambert et al., 1996), but there are differences beyond the mea- N sures. First, PCOMS is integrated into the ongoing psychotherapy process and d. ve routinely includes a transparent discussion of the feedback with the client er (Duncan et al., 2004). Session-by-session interaction is focused by client feed- es back about the benefits or lack thereof of psychotherapy. Second, PCOMS R assesses the therapeutic alliance every session and includes a discussion of any s ht potential problems. Lambert’s system includes alliance assessment only when ig there is a lack of progress. R Three studies have demonstrated the benefits of client feedback with ll .A the ORS and SRS. Miller, Duncan, Brown, Sorrell, and Chalk (2006) n explored the impact of feedback in a large, culturally diverse sample, using a tio ia telephonic employee assistance program (EAP). Although the study’s quasi- oc experimental design qualifies the results, the use of outcome feedback doubled ss overall effectiveness and significantly increased retention. Two recent RCTs lA used PCOMS to investigate the effects of feedback versus TAU. First, in an ca independent investigation, Reese, Norsworthy, and Rowlands (in press) found gi that clients who attended therapy at a university counseling center or a grad- lo ho uate training clinic demonstrated significant treatment gains for feedback yc when compared to TAU. Finally, our recent study in Norway (Anker, Ps Duncan, & Sparks, 2009), the largest RCT of couple therapy ever done, an found that feedback clients reached clinically significant change nearly ic four times more than non-feedback couples. The feedback condition main- er tained its advantage at 6-month follow-up and achieved nearly a 50% lower Am separation/divorce rate. Feedback is a powerful phenomenon. It improved ht the outcomes of 9 of 10 therapists in this study. rig An inspection of Figure 1.3 shows that feedback overlaps and affects all yop the factors—it is the tie that binds them together—allowing the other com-C mon factors to be delivered one client at a time. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitor- ing of outcome, heightens hope for improvement, fits client preferences, max- 26 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • imizes therapist–client fit and client participation, and is itself a core feature of therapeutic change. Feedback provides the means for clients to teach you how to do good work. It embodies the lessons I learned from Tina, providing for a transparent interpersonal process that solicits the client’s help in ensur- ing a positive outcome. At first blush, feedback may seem like an odd addition to the list of n. factors that cut across all approaches (Sparks & Duncan, 2010). The process of tio attaining formal client feedback and using that input to tailor services, how- bu ever, seems a worthy addition for several reasons. First, the effects of feedback tri is are independent of the measures used—a variety of outcome instruments rD have demonstrated a positive impact on outcome. Second, systematic feedback fo improves outcome regardless of the specific process used, whether in collabora- ot tion with clients or merely giving the feedback to therapists—over the phone N or face-to-face, paper-and-pencil administrations versus electronic formats, d. ve matters not. Third, feedback increases client benefit across professional disci- er pline, clinical setting, client population, as well as beginning or experienced es therapists. Fourth, feedback significantly improves outcome regardless of the R model practiced—the feedback process does not dictate what technique is used, s ht but rather is a vehicle to modify any delivered treatment for client benefit. Fifth, ig attaining informal client feedback about the benefit and fit of services is com- R ll mon among psychotherapists. Any goal-directed, symptom-oriented, or other .A approach that openly discusses the outcome of services is incorporating infor- n io mal client feedback into the therapeutic mix. Feedback speaks to an inter- t ia personal process of give and take between the clinician and client and, at least oc to some extent, can be argued to be characteristic of many therapeutic encoun- ss ters. Finally, the evidence regarding feedback continues to build. Feedback, lA then, similar to the history of the alliance, was initially viewed as an important ca aspect of conducting effective psychotherapy and is garnering a growing evi- gi lo dence base that supports a more formal understanding and systematic inclusion. ho yc Bottom Line: Given its broad applicability, lack of theoretical baggage, and Ps independence from any specific instrument or defined practice, feedback can be understood as a factor that demonstrably contributes to outcome regardless of an the model predilection of the clinician. ic er Common factors research provides general guidance for enhancing those Am elements shown to be most influential in positive outcomes. The specifics, ht however, can only be derived from the client’s response to any treatment rig delivered—the client’s feedback regarding progress in therapy and the quality yop of the alliance. Therapists need not know what approach should be used withC each disorder, but rather whether the delivered approach is a good fit for and benefits the client. The systematic collection of feedback only formalizes what most of us aspire to be: sensitive to client experiences and interested in results. SO YOU WANT TO BE A BETTER THERAPIST 27 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • Securing client feedback also exemplifies what Stricker and Trierweiler (1995) called the “local clinical scientist.” Positing that the clinical setting is analogous to the laboratory, Stricker and Trierweiler suggested that the inadequacy of any one model is reduced by embracing local observations and solutions to problems that are then subjected to the same need for verifiabil- ity that greets all scientific enterprises. That is what practice-based evidence n. intends to do—draw on the resources and ideas of clients and therapists while tio monitoring their impact on treatment benefit. bu tri is rD ABOUT THIS BOOK fo ot Feedback is the breakfast of champions. N —Ken Blanchard and Spencer Johnson, The One-Minute Manager d. ve Every day, more therapeutic approaches are proven effective, often pro- er fessing to be a “silver bullet” cure for what ails clients. At the same time, our es experience tells us that even the most empirically supported models “work” per- R fectly for one client, but do nothing for another. How do we make sense of the s ht “evidence” with the client in our office now? Moreover, we frankly do not even ig R know if our therapy is working or not—we often assume the best in the absence ll of reliable information. At the same time, we are painfully aware that some .A clients don’t benefit while others inexplicably end therapy. How can we really n io know where we stand with our clients, and retrieve those headed toward an t ia unsuccessful conclusion? Finally, despite our hard work and good intentions, oc the downsides of the work can sometimes steer us into ruts, influencing us to ss forget why we became therapists to begin with. How can we re-remember our lA original aspirations, continue to develop as therapists, and get in the zone more ca often with more clients? gi lo On Becoming A Better Therapist directly addresses these issues and ques- ho tions by drawing on the experiences of the two most important people to psy- yc chotherapy outcome: the client and you—client perspectives about the benefit Ps and fit of services and your perceptions of your professional growth. This book an embraces your noble intentions and encourages you to make the best of them ic regardless of your approach, helping you to continue to do what you are doing er well, but expanding your influence to those clients who do not respond to your Am usual efforts. Through a transparent process of attaining client feedback, you’ll ht learn ways to deepen the therapeutic conversation, intensify the power of a col- rig laborative alliance, and more effectively recruit clients’ own resources in the yop service of change. In short, you’ll accelerate your development and learn howC to become a better therapist—one client at a time. Psychotherapy is not an uninhabited landscape of technical procedures. It is not the sterile, stepwise process of surgery, nor does it follow the pre- 28 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • dictable path of diagnosis, prescription, and cure. It cannot be described with- out the client and therapist, co-adventurers in a journey across what is largely uncharted territory. The common factors provide useful directions for this intensely interpersonal and idiosyncratic trip, and specific models and tech- niques provide well-traveled routes to consider, but feedback offers a neces- sary compass to provide bearings of the psychotherapy terrain and guidance n. to the desired destination. tio This book has seven chapters. Chapter 2, “Just the Facts, Ma’am,” is a no- bu nonsense discussion about how to get started using feedback to help clients help tri is you do good work—not sometime, next month, or even next week—with your rD next client. It covers the first session pragmatics and details all you need to fo know to start becoming a better therapist. Chapter 3, “How Being Bad Can ot Make You Better,” cuts to the chase and describes how recapturing the clients N who are not benefiting from their contacts with you will make the difference d. between being an average therapist or a better one. Rather than learning les- ve sons from failed cases, this chapter details how to turn them around before a er es negative outcome ensues. “Getting in the Zone” and taking your development R seriously is the topic of Chapter 4. Integrating the groundbreaking work of s Orlinsky and Rønnestad, Chapter 4 discusses ways to increase your Healing ht ig Involvement and take charge of both your professional development and effec- R tiveness. Building on Chapter 4’s framework to track your growth and outcomes, ll .A Chapter 5, “The Heart and Soul of Change,” delineates strategies to improve n your effectiveness based on the most potent common factors—the client and io the therapeutic alliance. Chapter 6, “Wizards, Humbugs, or Witches,” encour- t ia ages you to reflect about your identity as a therapist and what it is that you do— oc to create a description of your work that you can believe in and that provides ss lA clinical flexibility. Chapter 6 and each of the preceding chapters conclude with ca a a story story that documents the lessons that clients have taught me over my gi career—meaningful moments that reminded me of why I made the choice to lo become a therapist. Finally, Chapter 7, “For the Love of the Work,” continues ho the focus on your development, exploring ways for continued reflection about yc the work you love. It concludes with my parting thoughts about the controver- Ps sial issues of the day as they pertain to our identity as therapists. an ic er CLIENTS ARE THE BEST TEACHERS: THEIR STORIES Am DOCUMENT OUR DEVELOPMENT ht rig At bottom every man [sic] knows well enough that he is a unique yop being, only once on this earth; and by no extraordinary chance will such a marvelously picturesque piece of diversity in unity as he is, everC be put together a second time. —Friedrich Nietzsche SO YOU WANT TO BE A BETTER THERAPIST 29 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • When I was an intern, I worked in an outpatient unit euphemisti- cally called the “Specialized Adult Services (SAS)” unit. While about a fifth of my referrals came from a stress management program, it was really an aftercare facility devoted to working with clients with the moniker “severely mentally ill.” By that time, I had acquired experiences in two community mental health centers (CMHCs) and an assessment/therapy n. tio stint in the state hospital. But the hospital experience lingered, leaving bu me with a bad taste in my mouth. I saw firsthand the facial grimaces and tri tongue wagging that characterize the neurological damage caused by is rD antipsychotics and sadly realized that these young adults would be for- ever branded as grotesquely different, as “mental patients.” I witnessed fo the dehumanization of people reduced to drooling, shuffling zombies, ot N spoken to like children and treated like cattle. I barely kept my head d. above water as hopelessness flooded the halls of the hospital, drowning ve staff and clients alike in an ocean of lost causes. I could not even imagine er what it would have been like to live there in the revolving-door fashion es that many were forced to endure. Now, in my internship position, my R s charge was to help people stay out of the hospital, and I took that charge ht quite seriously. ig R One of my first clients was Peter. Peter was not very liked at the SAS ll unit. He sometimes said ominous things to other clients in the waiting .A room, or often spoke in a boisterous way about how the fluorescent lights n io controlled his thinking through a hole in his head. When he wasn’t speak- t ia ing, he grunted and squealed and made other sounds like a pig. As a new oc intern, I was put under considerable pressure to address Peter’s less-than- ss lA endearing behaviors, particularly because he sometimes offended the stress ca management clients, who were seen as coveted treasures not to be messed gi with. Actually, I found Peter to be a terrific guy with a very dry sense of lo humor, but a man of little hope who lived in constant dread of returning to ho the state hospital. His behaviors were mostly his efforts to distract himself yc from tormenting voices that told him that people were trying to kill him Ps and other scary things. an Peter was routinely terrorized by these voices until he started taking ic er actions that would ultimately wind him up in the state hospital. He might Am empty his refrigerator for fear that someone had poisoned his food, creating a stench that would soon bring in the landlord and ultimately the authori- ht rig ties. Or, occasionally, he would start threatening or menacing others, those y he believed were trying to kill him. One time he took an empty rifle andop perched on an overpass trying to figure out who was on their way to kill him,C thinking he could ward them off. Once hospitalized, his medications were changed, usually increased in dose, and he essentially slept out the crisis. 30 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • These cycles occurred about every four to six months and had so for the last eight years. Peter’s treatment brought with it tardive dyskinesia and about a hundred pounds of extra weight. Peter hated the state hospital and I could truly commiserate, after my less-than-inspiring experience there. I felt profoundly sad for this young man, who was about the same age as me. I also felt completely helpless. n. tio Nothing in my training provided any guidance. I had no clue about what bu to do to be helpful to him. I was trying to apply strategies I learned from tri my supervisor about addressing the voices, which were helpful to others, is rD but not with Peter. I knew he was ramping up for another admission—he told me that he had already emptied his refrigerator and left it on the fo kitchen floor. I hit a brick wall. It seemed that nothing I said could con- ot N vince Peter to get off the merry-go-round to the state hospital. The anguish d. in his eyes about his impending hospitalization haunted me. ve Only because I had no clue about what to do, I asked Peter what he er thought it would take to get a little relief from his situation—what might es give him just a glimpse of a break from the torment of the voices and the R s revolving-door hospitalizations. After a long pause, Peter said something ht very curious—he said that it would help if he would start riding his bike ig R again. This led to my inquiry about the word “again.” Peter told me about ll what his life was like before the bottom fell out. Peter had been quite the .A competitive cyclist in college and was physically fit as only world class n io cyclists can be. I heard the story of a young man away from home for the first t ia time, overwhelmed by life, training day and night to keep his spot on the oc racing team, and topped off by falling in love for the first time. When the ss lA inevitable came to pass and the relationship ended, it was too much for ca Peter, and he was hospitalized, and then hospitalized again, then hospital- gi ized again, and so on until there was no more money or insurance—then lo the state hospitalization cycles ensued. ho On a roll now and enjoying a level of conversation not achieved yc before, I asked Peter what it would take to get him going again on his bike. Ps He said that his bike was in need of parts and what he needed was for me an to accompany him to the bike shop. Peter was afraid to go out in public ic er alone for fear of threatening someone and ending up in the hospital. I Am immediately consulted with my supervisor who had the good sense here (and on many occasions) to give me an enthusiastic green light. The next ht rig day, I went with Peter to the bike shop, where I bought a bike as well. y Peter and I started having our sessions biking together. Peter still strug-op gled with the voices at times, but he stayed out of the hospital and theyC never kept him from biking. He eventually joined a bike club and moved into an unsupervised living arrangement. SO YOU WANT TO BE A BETTER THERAPIST 31 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  • You can read a lot of books about schizophrenia and its treatment, but you’ll never find one that recommends biking as a cure. And you can read a lot of books about treatments in general, and you’ll never read a better idea about a client dilemma than will emerge from a client in con- versation with you—a person who cares and wants to be helpful. n. tio bu tri is rD fo ot N d. ve er es R s ht ig R ll n .A tio ia oc ss lA ca gi lo ho yc Ps an ic er Am ht yrigopC 32 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx