www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 1Heart and Soul of ChangeBecoming Better at What We DoBar...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 2••Since the 60’s, the # of modelsSince the 60’s, the # o...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 3••Considered most sophisticatedConsidered most sophistic...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 4••600 Adolescents marijuana users:600 Adolescents mariju...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 5The Search for the Holy GrailDoesn’t Do Much for UsThe S...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 6APA RecommendationsAPA Recommendations Decisions should...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 7Implication of the Dodo Bird VerdictImplication of the D...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 8Client/Life Factors (86%) (includes unexplained and erro...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 9PsychotherapyThe Bad…PsychotherapyThe Bad…Drop out rat...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 10Client/Life Factors (86%) (includes unexplained and err...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 11On Becoming BetterBottom LineOn Becoming BetterBottom L...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 12DiagnosisDiagnosis“I have found littlethat is good abou...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 13Diagnostic Screening TestDiagnostic Screening Test1. Li...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 14Casting the Client in Heroic RolesCasting the Client in...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 15Finding the Heroic ClientFinding the Heroic Client Who...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 16Sam—the Violent Suicidal ManSam—the Violent Suicidal Ma...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 17The Heroic ClientThe Heroic Client• The Client:• The Cl...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 18•Strong correlation between the maintenance of changeMa...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 19EncourageEncourage Beforeandand After DistinctionsDisti...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 20The Heroic StoryThe Heroic Story Story of a overcoming...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 21ClientsThe Heart of ChangeClientsThe Heart of ChangeCli...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 22Client/Life Factors (86%) (includes unexplained and err...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 23The Therapeutic AllianceThe Therapeutic AllianceTh Alli...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 24Reliance on theon the Alliance• Be friendly, responsive...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 25The More Cognitive AspectsAgreement about Goals & Tasks...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 26•Meta-analysis of 35 studies ofclient preference: ES of...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 27The Client’s Theory of Change:The Client’s Theory of Ch...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 28mandated, never been in a goodrelationship abusedWe All...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 29When the alliance is in trouble…When the alliance is in...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 30Lisbeth’s Heroic StoryLisbeth’s Heroic Story Story of ...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 31Attitude ImportantAlliance is Central FilterAttitude Im...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 32The AllianceThe of ChangeThe AllianceThe of ChangeAllia...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 33And the UglyProviders Don’t KnowAnd the UglyProviders D...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 34Feedback and OutcomeLambert’s Six TrialsFeedback and Ou...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 35Improving or NotTwo Choices: Not Rocket ScienceImprovin...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 36Barry Finds the Spot in the Norway PictureBy Coincidenc...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 37Meta-analysis by Lambert & Shimokawa (2011)of PCOMS (th...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 38Two More in the WorksVeterans and YouthSubmitted: RCT C...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 39President Kennedy Signed the Mental Health Act on Oct31...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 40Reported a combined reliableand clinically significant ...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 41Southwest Behavioral HealthPublic Behavioral HealthRees...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 42In Fact, Client BasedOutcome FeedbackIn Fact, Client Ba...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 43And…FinallyAnd…Finally Puts the client’s voicet t Put...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 44First Things FirstWhy You Might Be ReluctantFirst Thing...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 45Counselors OutcomesProvider VariationFeedback Improves ...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 46 You might be thinking You might be thinkingFirst Thi...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 47Getting the Max Out of the MeasuresJust the Facts Ma’am...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 48The Measures and Social Justice“Leveling” the Counselin...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 49Who drops out?Sooner Rather Than LaterAB•The bulk ofcha...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 50Cannabis Youth Treatment ProjectEarly change inIt’s A F...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 51••Give at theGive at theBecoming BetterMeasuring Outcom...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 52The ORS Is Different ThanOther Outcome MeasuresThe ORS ...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 53The Outcome Rating ScaleAn Introduction in Your Own Wor...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 54The First MeetingIntroducing the ORSThe First MeetingIn...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 55The Clinical CutoffOnly 2 ChoicesThe Clinical CutoffOnl...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 56ORS: An ExampleORS: An Example••What can we gleanWhat c...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 57Take Clients at Face ValueTake Clients at Face Value P...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 58The ORSThe Bare BonesThe ORSThe Bare Bones No specific...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 59Get A Good RatingMake SureGet A Good RatingMake SureT t...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 60Clients drop out for 2Quickest WayPrevent Drop OutQuic...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 61Becoming BetterA Culture of Feedback with the SRSBecomi...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 62The Session Rating ScaleAn Introduction in Your Own Wor...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 63The Session Rating ScaleTraditionallyThe Session Rating...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 64The Session Rating ScaleA Quick Visual CheckThe Session...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 65The SRSGraceful AcceptanceThe SRSGraceful Acceptance A...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 66Granted at firstSage Psychotherapy Scholar:Mae West?Gra...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 67Becoming BetterIdentifying Clients Not RespondingBecomi...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 68Becoming BetterWhen I’m Good, I’m Very GoodBecoming Bet...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 69Becoming BetterDoesn’t Mean All Therapy Should Be Brief...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 70 Okay, so things haven’t changed since Okay, so thing...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 71Checkpoint Session:An Opportunity to Be BetterCheckpoin...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 72Checkpoint ConversationDo Something DifferentCheckpoint...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 73Becoming BetterNever the LAST CHANCEBecoming BetterNeve...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 74Becoming BetterHelping Every Single ClientBecoming Bett...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 75When I’m Bad, I’m BetterFailing SuccessfullyWhen I’m Ba...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 76Failing SuccessfullyFailing SuccessfullyChange of Thera...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 77Becoming BetterGuard Against Finger PointingBecoming Be...
www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 78Being BadCan Make You BetterBeing BadCan Make You Bette...
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UpdatedOneDayWorkshop

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Updated with the latest research about the alliance and other common factors, this one day workshop covers PCOMS and its implementation.

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  1. 1. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 1Heart and Soul of ChangeBecoming Better at What We DoBarry Duncan,Barry Duncan, Psy.DPsy.D. www.heartandsoulofchange.com. www.heartandsoulofchange.com561.239.3640 barrylduncan@comcast.net561.239.3640 barrylduncan@comcast.net
  2. 2. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 2••Since the 60’s, the # of modelsSince the 60’s, the # of modelshas grown from 60 to over 400…has grown from 60 to over 400…••Each claims superiority inEach claims superiority inli i dli i dconceptualization and outcomeconceptualization and outcomeThe result is fragmentation alongThe result is fragmentation alongtheoretical and disciplinary linestheoretical and disciplinary linesp yp yNow overNow over 150150 so called evidenceso called evidencebased treatments, butbased treatments, butironically…ironically…The Dodo VerdictThe Dodo Verdict••With few exceptions, partisan studiesWith few exceptions, partisan studiesd i d h i ffd i d h i ffdesigned to prove the unique effectsdesigned to prove the unique effectsof a given model have found noof a given model have found nodifferencesdifferences——nornor havehave recent metarecent meta--analyses…The Dodo Verdict—themost replicated finding in thepsychological literaturepsychological literature“Everybody has won and all“Everybody has won and allmust have prizes.”must have prizes.”Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy.Journal of Orthopsychiatry, 6, 412-15.Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fidepsychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215.
  3. 3. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 3••Considered most sophisticatedConsidered most sophisticatedTDCRPThe AllianceTDCRPThe Alliance••Considered most sophisticatedConsidered most sophisticatedcomparative clinical trial ever:comparative clinical trial ever:••CBT, IPT, Drug, PlaceboCBT, IPT, Drug, Placebo•No difference in outcomein outcome••TheThe client’sclient’s rating of the alliance atrating of the alliance atElkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of GeneralPsychiatry, 46, 971-82.ggthe second session the best predictorthe second session the best predictorof outcome across conditions.of outcome across conditions.••CBT, 12CBT, 12--step, & Motivationalstep, & MotivationalProject MATCHThe AllianceProject MATCHThe Alliance,, p,p,InterviewingInterviewing••NONO differencedifference in outcomein outcome••The client’s rating of the allianceThe client’s rating of the alliancethe best predictor of:the best predictor of:Treatment participation;Treatment participation;D i ki b h i d iD i ki b h i d iDrinking behavior duringDrinking behavior duringtreatment;treatment;Drinking at 12Drinking at 12--month FUmonth FUProject MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29.Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK.Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journalof Consulting and Clinical Psychology, 65(4), 588-98.
  4. 4. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 4••600 Adolescents marijuana users:600 Adolescents marijuana users:••Significant coSignificant co morbidity (3morbidity (3 12 problems)12 problems)The Dodo Also Rules FamilyThe Dodo Also Rules Family WorkWorkCannabis Youth Treatment ProjectCannabis Youth Treatment Project••Significant coSignificant co--morbidity (3morbidity (3--12 problems).12 problems).••Two arms (dose, type) and one ofTwo arms (dose, type) and one ofthree types of treatment in each arm:three types of treatment in each arm:••Dose arm: MET+CBT (5 wks),Dose arm: MET+CBT (5 wks),MET+CBT (12 wks), Family SupportMET+CBT (12 wks), Family SupportNetwork (12 wks)+MET+CBT;Network (12 wks)+MET+CBT;( ) ;( ) ;••Type arm: MET/CBT (5 wks), ACRT (12Type arm: MET/CBT (5 wks), ACRT (12weeks), MDFT (12 wks).weeks), MDFT (12 wks).No Difference! ApproachApproach accounted for 0% of the variance in outcome.accounted for 0% of the variance in outcome.AllianceAlliance predicted: Premature droppredicted: Premature drop--out; Substance abuseout; Substance abuse symptomssymptoms postpost--treatment, and cannabis use at 3 and 6 month followtreatment, and cannabis use at 3 and 6 month follow--up.up.Evidenced Based TreatmentNone Have Shown SuperiorityEvidenced Based TreatmentNone Have Shown Superiority••Nothing wrong with EBTs but DodoNothing wrong with EBTs but Dodohighlights fatal flaw:highlights fatal flaw: Being betterBeing betterthan placebo/TAU is notthan placebo/TAU is not sayingsayingmuchmuch——ifif a friend went out on adate, you asked about the guy, yourfriend replied, “He was better thanthi h i llRosenzweig, S. (1936). Some implicit commonRosenzweig, S. (1936). Some implicit commonfactors in diverse methods in psychotherapy.factors in diverse methods in psychotherapy.Journal of Orthopsychiatry, 6Journal of Orthopsychiatry, 6, 412, 412--15.15.nothing—he was unequivocallybetter than watching TV or washingmy hair.” How impressed?How impressed?••And the conclusionAnd the conclusion……
  5. 5. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 5The Search for the Holy GrailDoesn’t Do Much for UsThe Search for the Holy GrailDoesn’t Do Much for Us Helping is no more Helping is no morep geffective now with allour treatmenttechnologies (400 ofthem) and empiricallyp geffective now with allour treatmenttechnologies (400 ofthem) and empiricallythem) and empiricallysupported treatments(almost 150 of them)than 40 years ago.them) and empiricallysupported treatments(almost 150 of them)than 40 years ago.APA Definition of EBPAPA Definition of EBPEvidence-basedi i hEvidence-basedi i hpractice is theintegration of the bestavailable research withclinical expertise in thecontext of clientpractice is theintegration of the bestavailable research withclinical expertise in thecontext of clientcontext of clientcharacteristics, culture,and preferences(American Psychologist,May 2006).context of clientcharacteristics, culture,and preferences(American Psychologist,May 2006).
  6. 6. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 6APA RecommendationsAPA Recommendations Decisions should be made incollaboration with the client, Decisions should be made incollaboration with the client,,based on the best evidence Most effective whenresponsive to the client’sstrengths, cultural context,and preferences.,based on the best evidence Most effective whenresponsive to the client’sstrengths, cultural context,and preferences. Responses are variable.Therefore, ongoingmonitoring of client progressand adjusting as needed isessential Responses are variable.Therefore, ongoingmonitoring of client progressand adjusting as needed isessential: A SAMHSA EBPBut Different: A SAMHSA EBPBut DifferentPCOMS is a-theoretical &therefore additiveto any therapeuticorientation,including otherc ud g o eEBPs; PCOMSapplies to clients ofall diagnosticcategories
  7. 7. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 7Implication of the Dodo Bird VerdictImplication of the Dodo Bird VerdictAll 400 approaches workAll 400 approaches workbecause:Of factors common to allOf factors common to allSo what are the factors?So what are the factors?40.0%40.0%Factors Accounting forFactors Accounting forSuccessful Outcome30 0%30 0%Spontaneous RemissionSpontaneous RemissionClient/ExtratherapeuticClient/ExtratherapeuticCommon FactorsCommon FactorsRelationshipRelationshipModels/TechniquesModels/Techniques30.0%30.0%15.0%15.0%15.0%15.0%Lambert, M. (1986). Implications of Psychotherapy Outcome Research for Eclectic Psychotherapy.In J. Norcross (Ed.) Handbook of Eclectic Psychotherapy. New York: Brunner/Mazel.Placebo/Hope/ExpectancyPlacebo/Hope/Expectancy
  8. 8. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 8Client/Life Factors (86%) (includes unexplained and error variance)Feedback Effects21‐42%Alliance EffectsTreatment Effects14% Alliance Effects36‐50% Model/Technique:Specific Effects (Model Differences)7%Model/Technique: General Effects (Rational &  Ritual), Client Expectancy (Placebo), & Therapist Allegiance28‐?%Therapist Effects36‐57%PsychotherapyThe Good…PsychotherapyThe Good…Study after studyStudy after studyStudy after study,Study after study,and studies ofand studies ofstudies show thestudies show theaverage treatedaverage treatedclient is better offclient is better offthan 80% of thethan 80% of theuntreated sample.untreated sample.
  9. 9. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 9PsychotherapyThe Bad…PsychotherapyThe Bad…Drop out ratesDrop out ratesDrop out ratesDrop out ratesaverageaverage 47%,47%,60% with60% with adoladol..& SA clients& SA clients& SA clients& SA clientsTherapists vary…Therapists vary…a lota lotTDCRP: top thirdh l bTherapist DifferencesIncredible Variation Among ProvidersTherapist DifferencesIncredible Variation Among Providerspsychiatrists giving placebobested bottom third givingmeds; clients of bestcounselors improve 50%more & dropped out 50%ppless; meds useful for clientsof more effective, not forless--What accounts for thevariability?Wampold, B., & Brown, J. (2006). Estimating variability inoutcomes attributable to therapists: A naturalistic study ofoutcomes in managed care. Journal of Consulting andClinical Psychology, 73 (5), 914-923.
  10. 10. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 10Client/Life Factors (86%) (includes unexplained and error variance)Feedback Effects21‐42%Alliance EffectsTreatment Effects14% Alliance Effects36‐50% Model/Technique:Specific Effects (Model Differences)7%Model/Technique: General Effects (Rational &  Ritual), Client Expectancy (Placebo), & Therapist Allegiance28‐?%Therapist Effects36‐57%Successful V. Unsuccessful CounselorsFocus on StrengthsSuccessful V. Unsuccessful CounselorsFocus on StrengthsStudied videos of 120Studied videos of 120sessions of 30 clients. Unsuccessful helpers focusedon problems, neglectedstrengths.sessions of 30 clients. Unsuccessful helpers focusedon problems, neglectedstrengths. Successful helpers focused onrecruiting strengths to addressproblems…. Successful helpers focused onrecruiting strengths to addressproblems….Gassman, D. & Grawe, K. (2006). General change mechanisms: The relation between problem activation and resource activationin successful and unsuccessful therapeutic interactions. Clinical Psychology and Psychotherapy, 13, 1-11.
  11. 11. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 11On Becoming BetterBottom LineOn Becoming BetterBottom Line“The quality ofPrivilege clients’experience & rallytheir resources tothe cause.Privilege clients’experience & rallytheir resources tothe cause.q ythe patientsparticipation . . .[emerges] asthe mostimportant But nooooooooooo! But nooooooooooo!importantdeterminant ofoutcome."Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years ofprocess -outcome research: In M. J. Lambert (Ed.), Bergin andGarfield’s handbook of psychotherapy and behavior change (5th ed.,pp. 307-390). New York: Wiley.DysfunctionThe Killer D’s ofThe Killer D’s ofClient DiminishmentDisorderDisabilityDiseaseDeficitD dDamagedNot Reliable or ValidNone ever related tooutcome
  12. 12. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 12DiagnosisDiagnosis“I have found littlethat is good abouthuman beings. In myexperience, most ofh h ”them are trash.”--Sigmund Freud, M.D.“Psychotherapy is the only form of treatmentwhich, at least to some extent, appears to createthe illness it treats” Jerome Frank (Frank 1961More Quotable Quotes about Diagnosisthe illness it treats Jerome Frank (Frank, 1961,p. 7).Reliability: “To say that weve solved thereliability problem is just not true…Its beenimproved. But if youre in a situation with ageneral clinician its certainly not very good.Theres still a real problem, and its not clearhow to solve the problem" Robert Spitzer, lead•Creates the Illness•Reliability not goodGet Over it!p peditor of DSM III (Spiegel, 2005, p. 63).Validity: “There is no definition of a mentaldisorder. It’s bullshit. I mean, you just can’tdefine it… these concepts are virtuallyimpossible to define precisely with bright lines atthe boundaries.” Allen Francis, lead editor ofDSM IV (Greenberg, 2010, p. 1).•Reliability not good•It’s BS
  13. 13. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 13Diagnostic Screening TestDiagnostic Screening Test1. Lift your right foot off the1. Lift your right foot off they gfloor and make clockwisecircles.2. Now, while doing this, drawthe number "6" in the airwith your right hand.y gfloor and make clockwisecircles.2. Now, while doing this, drawthe number "6" in the airwith your right hand.3. If your foot changesdirection, you need drugs ortherapy or both.3. If your foot changesdirection, you need drugs ortherapy or both.Clients Are the Lions of ChangeUntil lions have theirUntil lions have theirhistorians, tales ofhistorians, tales ofhunting will alwayshunting will alwaysglorify the hunterglorify the hunterglorify the hunter.glorify the hunter.African Proverb
  14. 14. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 14Casting the Client in Heroic RolesCasting the Client in Heroic Roles No formula here, more of an attitude No formula here, more of an attituderequiring a balance betweenlistening empathically withmindfulness toward resources thatyou know are there. Identify not what clients need butrequiring a balance betweenlistening empathically withmindfulness toward resources thatyou know are there. Identify not what clients need but Identify not what clients need, butwhat they already have in their worldthat can be put to use in reachingtheir goals Identify not what clients need, butwhat they already have in their worldthat can be put to use in reachingtheir goalsFinding the Heroic ClientFinding the Heroic ClientWhat are the qualities that describe you whenyou are your very best? What were you doingWhat are the qualities that describe you whenyou are your very best? What were you doingwhen these aspects became apparent to you?What kind of person do these aspects describe?Or, What kind of person do these aspects show anaspiration toward?What are the qualities that others would describewhen these aspects became apparent to you?What kind of person do these aspects describe?Or, What kind of person do these aspects show anaspiration toward?What are the qualities that others would describeWhat are the qualities that others would describeIn you when you are at your very best? Whatwere you doing when they noticed these aspects?What kind of person do these aspects describe?Or, what kind of person do these aspects show anaspiration toward?What are the qualities that others would describeIn you when you are at your very best? Whatwere you doing when they noticed these aspects?What kind of person do these aspects describe?Or, what kind of person do these aspects show anaspiration toward?
  15. 15. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 15Finding the Heroic ClientFinding the Heroic Client Who was the first person to tell you that theynoticed the best of you in action? What were Who was the first person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects? Who was the last person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects? Who in your life wouldn’t be surprised to seeyou stand up to these situations and prevail?you doing when they noticed these aspects? Who was the last person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects? Who in your life wouldn’t be surprised to seeyou stand up to these situations and prevail?you stand up to these situations and prevail?What experiences would they draw upon tomake these conclusions about you? What“quintessentially you” stories would theytell?...Kim When I am at my very best, I am_____________.you stand up to these situations and prevail?What experiences would they draw upon tomake these conclusions about you? What“quintessentially you” stories would theytell?...Kim When I am at my very best, I am_____________.Telling Heroic StoriesTelling Heroic Stories What are the obvious and hiddent th ili i What are the obvious and hiddent th ili istrengths, resources, resiliencies,and competences contained in theclient’s story? What are the competing stories—thestories of clarity, coping, endurance,and desire that exist simultaneouslystrengths, resources, resiliencies,and competences contained in theclient’s story? What are the competing stories—thestories of clarity, coping, endurance,and desire that exist simultaneouslyand desire that exist simultaneouslywith the confusion, pain, suffering,and desperation? What is already there to be recruitedfor change?and desire that exist simultaneouslywith the confusion, pain, suffering,and desperation? What is already there to be recruitedfor change? The Heroic Client
  16. 16. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 16Sam—the Violent Suicidal ManSam—the Violent Suicidal Man Story of “Threats” Story of “Threats”y Story of “Suicide”St f “Sty Story of “Suicide”St f “St Story of “StrangeBeliefs”…wants anapocalypse Story of “StrangeBeliefs”…wants anapocalypseSam’s Heroic StorySam’s Heroic Story Story of a man with ai i id Story of a man with ai i idwarrior inside. Story of a man who controlshis rage.warrior inside. Story of a man who controlshis rage. Story of a natural bornleader wanting to do somegood in the world. Story of a natural bornleader wanting to do somegood in the world.
  17. 17. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 17The Heroic ClientThe Heroic Client• The Client:• The Client:•• Change is a potent client factor,Change is a potent client factor,weaving in and out clients’ livesweaving in and out clients’ livescreating many therapeuticcreating many therapeuticopportunities.opportunities.• Chance events:• Chance events:•• Things that simply happenThings that simply happenwhile the person happens to bewhile the person happens to bein therapy…in therapy…ChangeChange HappensHappensSource: Howard, et al (1986). The dose effect response in psychotherapy. American Psychologist,41(2), 159-164.
  18. 18. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 18•Strong correlation between the maintenance of changeMaintaining ChangeMaintaining Changeand the degree to which clients attribute it to their ownefforts.•Participants who attribute changes to a med or therapist are lesslikely to maintain gains than those who viewed the improvementresulting from their own efforts.•Those who attribute changes to their own efforts rather thanchance more likely to maintain gains regardless of the cause.Frank, J.D. (1976). Psychotherapy and the sense of mastery. In R.L. Spitzer et al. (eds). Evaluation ofPsychotherapies. Baltimore, MD: Johns Hopkins.Liberman, B. (1978). The maintenance and persistence of change. In J.D. Frank et al. (eds). Effective ingredients ofeffective psychotherapy. New York: Brunner Mazel.Becoming Change FocusedBecoming Change Focused Listen for a change!Listen for a change! AskAskabout and be curious aboutabout and be curious about Listen for a change!Listen for a change! AskAskabout and be curious aboutabout and be curious aboutchange: How did you dochange: How did you dothat? Where did that ideathat? Where did that ideacome from?come from? Validate the clientsValidate the clientscontribution to change.contribution to change.change: How did you dochange: How did you dothat? Where did that ideathat? Where did that ideacome from?come from? Validate the clientsValidate the clientscontribution to change.contribution to change.How is (drug/How is (drug/txtx program)program)helping accesshelping access resourcesresourcesthat have always been therethat have always been therebut were just beyond yourbut were just beyond yourgrasp? Change builds Heroicgrasp? Change builds HeroicStoriesStoriesHow is (drug/How is (drug/txtx program)program)helping accesshelping access resourcesresourcesthat have always been therethat have always been therebut were just beyond yourbut were just beyond yourgrasp? Change builds Heroicgrasp? Change builds HeroicStoriesStories
  19. 19. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 19EncourageEncourage Beforeandand After DistinctionsDistinctionsEncourageEncourage Beforeandand After DistinctionsDistinctions How did you decide that now was thetime for action? How did you decide that now was thetime for action? What insights have you gained that youwere finally able to put into action? What insights have you gained from thischange that will help you in the future? What does this say about you, the kindof person that took the bull by the hornsat this time? What insights have you gained that youwere finally able to put into action? What insights have you gained from thischange that will help you in the future? What does this say about you, the kindof person that took the bull by the hornsat this time? How did you do it? How will youmaintain the gains you have made? How are you different now that youhave realized this change? Ponder the difference in your self-imagebefore you changed and now. How did you do it? How will youmaintain the gains you have made? How are you different now that youhave realized this change? Ponder the difference in your self-imagebefore you changed and now.Liz and CarlieFamily in ConflictLiz and CarlieFamily in Conflict Story of “ongoing Story of “ongoingconflict” Story of “borderlinemom”conflict” Story of “borderlinemom” Story of “lack ofrespect and discipline” Story of “lack ofrespect and discipline”
  20. 20. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 20The Heroic StoryThe Heroic Story Story of a overcomingd it Story of a overcomingd itadversity Story of getting better overtimeadversity Story of getting better overtime Story of a playful, lovingmother/daughter relationship Story of a playful, lovingmother/daughter relationshipClient is the of ChangeClient is the of Change Client’s Resources, Client’s Resources,,Resiliencies, andRelational Support Client’s View of theAlliance,Resiliencies, andRelational Support Client’s View of theAlliance Client’s View ofProgress&Expectation ofSuccess Client’s View ofProgress&Expectation ofSuccess
  21. 21. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 21ClientsThe Heart of ChangeClientsThe Heart of ChangeClient outcome feedbackmakes consumers thehistorians of their ownchangeClient outcome feedbackmakes consumers thehistorians of their ownchangePartnering w/clients tomonitor outcome engagesmost the potent factor ofchangePartnering w/clients tomonitor outcome engagesmost the potent factor ofchangeTherapist Variables thatPredict ChangeTherapist Variables thatPredict ChangeTherapists with theTherapists with thebest results: Are better at thealliance acrossclients; alliancebest results: Are better at thealliance acrossclients; allianceclients; allianceability accounts fortherapistdifferencesclients; allianceability accounts fortherapistdifferencesBaldwin et al. (2007). Untangling the alliance-outcomecorrelation. Journal of Consulting and Clinical Psychology,75(6), 842-852.;Owen, Duncan, Anker, & Sparks (in press). Therapisteffects in couple therapy. Journal of Family Psychology.
  22. 22. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 22Client/Life Factors (86%) (includes unexplained and error variance)Feedback Effects21‐42%Alliance EffectsTreatment Effects14% Alliance Effects36‐50% Model/Technique:Specific Effects (Model Differences)7%Model/Technique: General Effects (Rational &  Ritual), Client Expectancy (Placebo), & Therapist Allegiance28‐?%Therapist Effects36‐57%Relationship FactorsRelationship FactorsThe Alliance:•• Relational BondRelational Bond•• Agreement onAgreement on goals• Agreement on tasksAgreement on tasksS Ti th I t fth I t f36-50%Duncan, B. (2010). On Becoming a Better Therapist. Washington, DC: APASeven Times the Impact ofthe Impact ofModel/Technique…AccountsModel/Technique…Accountsfor Most offor Most of CounselorCounselorVarianceVariance
  23. 23. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 23The Therapeutic AllianceThe Therapeutic AllianceTh AlliTh AlliMeans orMeans orMethods:Methods:Theory ofTheory ofChChGoals,Goals,MeaningMeaningororPPThe AllianceThe AllianceChangeChangePurposePurposeClient’s View of theClient’s View of theRelationshipRelationshipThe Alliance:The Alliance:OverOver 1000 Research FindingsResearch Findings Quality of the alliance more Quality of the alliance morepotent predictor of outcome thanorientation, experience, orprofessional discipline-- recallTDCRP, MATCH, CYT. Clients rarely report negativey p greactions before deciding toterminate. Same holds true for youth andfamily services
  24. 24. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 24Reliance on theon the Alliance• Be friendly, responsive, andflexible (like a first date); stayflexible (like a first date); stayclose to client’s experience.• Empathy, Positive Regard,Genuineness: AuthenticallyValidate. Legitimize the client’sgconcerns/basic worth and theimportance of their struggle.• Work on client’s goals period.• Fit the client’s theory of change.Empathy, Positive Regard, GenuinenessCarl Rogers Was On To SomethingEmpathy, Positive Regard, GenuinenessCarl Rogers Was On To Something Empathy: Meta-analysis of 57studies found r of 31; Empathy: Meta-analysis of 57studies found r of 31;studies found r of .31; Positive Regard: Meta-analysis of 18 studies found rof .27; Genuineness: Meta-analysisstudies found r of .31; Positive Regard: Meta-analysis of 18 studies found rof .27; Genuineness: Meta-analysis Genuineness: Meta analysisof 16 studies found r of .24 Each more powerful than anytechnique you can ever wield(Lambert, 2013). Genuineness: Meta analysisof 16 studies found r of .24 Each more powerful than anytechnique you can ever wield(Lambert, 2013).
  25. 25. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 25The More Cognitive AspectsAgreement about Goals & TasksGoals: When we ask clients whatthey want we give credibility tothey want, we give credibility totheir beliefs & values.• Tasks: specific tech. or points ofview, topics of conv., procedures,freq. of meeting, & the nuts andbolts—all count for or against us.• In our F/U study we found that thehighest category of complaintswas these everyday aspects• Alliance depends on thedelivery of some tx; Can’t haveCollaborating to Set the TasksOur Biggest Blind Spotdelivery of some tx; Can t havea good alliance w/o agreementabout how therapy is going toaddress the issues at hand.• Meta-analysis of 19 studies ofygoal consensus & taskcollaboration, & outcome:found correlation of .33; againbigger than relationshipbetween technique & outcome.
  26. 26. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 26•Meta-analysis of 35 studies ofclient preference: ES of 31 &Perhaps the Most Important IsWhether It Fits Client Preferencesclient preference: ES of .31 &less drop out•Traditionally, we search forideas that promote change &validate our favored theory.yServing the alliance requires asearch for ideas that promotechange by validating the client’sview of what is helpful—theclient’s theory of changeThe Client’s Theory of ChangeThe Client’s Theory of ChangePrePre--existing beliefsexisting beliefsabout the problemabout the problemand changeand changeSource: Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the Rules. NewYork: Guilford.
  27. 27. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 27The Client’s Theory of Change:The Client’s Theory of Change:Empirical FindingsIn the TDCRP, congruence betweenthe clients TOC and tx resulted in:Stronger therapeutic alliances;Longer duration in treatment; andg ;Improved treatment outcomes.Elkin, I. (1999). “Patient-treatment fit" and early engagement in therapy. Psychotherapy Research. 9(4) 437-451.Plurality Pays OffDifferential Efficacy with Current ClientPlurality Pays OffDifferential Efficacy with Current Client Q: Does it resonate? does it fitclient preferences; can both Q: Does it resonate? does it fitclient preferences; can bothclient preferences; can bothget behind it? Alliance skills: explore clientideas & options, collaborativelyplan, & negotiate changes ifh lclient preferences; can bothget behind it? Alliance skills: explore clientideas & options, collaborativelyplan, & negotiate changes ifh lnot helping. Alliance in action. Litmus test:whether it engages client inpurposive work.not helping. Alliance in action. Litmus test:whether it engages client inpurposive work.
  28. 28. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 28mandated, never been in a goodrelationship abusedWe All Have Clients Who ConnectQuickly: But What About Folks…relationship, abused,traumatized, never get a breakor have lost hope?Our job is the same—engagethe client in purposeful work.p pThis separates the best from therest. It’s hard work, “therapeuticwork” applies to us too. Have toearn this, put ourselves outthere every time. Daunting task•It gets such little press compared tod l d t h i d i ftBut Perpetually Minimized inDifficulty and ImportanceBut Perpetually Minimized inDifficulty and Importancemodels and techniques and is oftenrelegated to statements like “first gainrapport and then…” or “form arelationship and then…” as if it issomething we effortlessly do beforethe real intervention starts Thethe real intervention starts. Thealliance is not the anesthesia tosurgery.••The alliance deserves farThe alliance deserves farmoremore RESPECT…
  29. 29. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 29When the alliance is in trouble…When the alliance is in trouble…Consider…Lisbeth and SophieLisbeth and SophieAbused KidAbused KidAbused KidAngry KidDefiant KidAbused KidAngry KidDefiant KidViolent KidFoul-Mouthed KidViolent KidFoul-Mouthed Kid
  30. 30. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 30Lisbeth’s Heroic StoryLisbeth’s Heroic Story Story of a brilliant girlovercoming incredible obstacles; Story of a brilliant girlovercoming incredible obstacles;overcoming incredible obstacles;many strengths; crusty oldsailor, salty. Story of a girl who wants to setthe record straight; story of aovercoming incredible obstacles;many strengths; crusty oldsailor, salty. Story of a girl who wants to setthe record straight; story of ag ; ygirl who loves horses. Story of an amazing fostermom, one in a million. And a crusty old man, Barryg ; ygirl who loves horses. Story of an amazing fostermom, one in a million. And a crusty old man, BarryThe Rubber Hose of Doubtand the Bright Light of BlameThe Rubber Hose of Doubtand the Bright Light of BlameYou are the problem!Y t bl ! Validation doesn’t mean you agree withwhat the client has done; means thatyou acknowledge the rest of the story! Puts client’s actions in a context thatlegitimizes him/her as a human being Validation doesn’t mean you agree withwhat the client has done; means thatyou acknowledge the rest of the story! Puts client’s actions in a context thatlegitimizes him/her as a human beingYou are to blame!legitimizes him/her as a human being.No wonder… Clears a path for change because itdiffuses self doubt and dissipates selfloathing…Sam & Lisbethlegitimizes him/her as a human being.No wonder… Clears a path for change because itdiffuses self doubt and dissipates selfloathing…Sam & Lisbeth
  31. 31. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 31Attitude ImportantAlliance is Central FilterAttitude ImportantAlliance is Central Filter Is what I am doing and Is what I am doing and Is what I am doing andsaying now building orrisking the alliance? Doesn’t mean you can’tchallenge but rather Is what I am doing andsaying now building orrisking the alliance? Doesn’t mean you can’tchallenge but ratherchallenge but ratherthat you have to earnthe right and, consideralliance consequenceschallenge but ratherthat you have to earnthe right and, consideralliance consequencesAlliance As An Overarching FrameworkThe Alliance is the SoulAlliance As An Overarching FrameworkThe Alliance is the Soul Transcends any beh & is Transcends any beh & isa property of all—fromtech. to scheduling appt Purpose is to engage inpurposive worka property of all—fromtech. to scheduling appt Purpose is to engage inpurposive work Have to earn it each &every time; alliance isour craft; practiceelevates to art Have to earn it each &every time; alliance isour craft; practiceelevates to art
  32. 32. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 32The AllianceThe of ChangeThe AllianceThe of ChangeAlliance feedback enables a fitbetween client expectations,preferences, and servicesDoes not leave the alliance tochance—applying over 1000studies showing therelationship of the alliance topositive outcomesReliance on the AllianceReliance on the AllianceThe Alliance isthe Best FriendWe Have in theWe Have in theTherapy Room
  33. 33. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 33And the UglyProviders Don’t KnowAnd the UglyProviders Don’t Know 20-70% range 20-70% rangeg Graded theireffectiveness, A+ to F—67% said A or better;none rated belowg Graded theireffectiveness, A+ to F—67% said A or better;none rated belowaverage. ProvidersProviders don’t knowdon’t knowhow effective they arehow effective they areaverage. ProvidersProviders don’t knowdon’t knowhow effective they arehow effective they areHansen, N., Lambert, M., Forman, E. (2002). Thepsychotherapy dose-response effect and itsimplications for treatment delivery services. ClinicalPsychology: Science and Practice, 9, 329-343.Sapyta, J., Riemer, M., & Bickman, L. Feedback toclinicians: Theory, research, and practice. Journalof Clinical Psychology: In Session, 61, 145-153To The RescueConsumer Driven Outcomes ManagementTo The RescueConsumer Driven Outcomes Management Howard et al. (1996) advocatedf th t ti l f li t Howard et al. (1996) advocatedf th t ti l f li tfor the systematic eval. of clientresponse during treatment to“determine the appropriatenessof the current tx…the need forfurther tx…[and] prompt afor the systematic eval. of clientresponse during treatment to“determine the appropriatenessof the current tx…the need forfurther tx…[and] prompt aclinical consultation for patientswho [were] not progressing atexpected rates”clinical consultation for patientswho [were] not progressing atexpected rates”
  34. 34. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 34Feedback and OutcomeLambert’s Six TrialsFeedback and OutcomeLambert’s Six Trials All 6 sig. gains for feedback All 6 sig. gains for feedback 22% of TAU at-risk casesimproved compared with 33%for feedback to therapists,39% for feedback totherapists & clients, & 45%h l t d ith 22% of TAU at-risk casesimproved compared with 33%for feedback to therapists,39% for feedback totherapists & clients, & 45%h l t d ithwhen supplemented withsupport tools A strong case for routinemeasurement of outcome ineveryday clinical practicewhen supplemented withsupport tools A strong case for routinemeasurement of outcome ineveryday clinical practicePCOMSOutcome and Alliance FeedbackPCOMSOutcome and Alliance FeedbackTheThe ORSORS TheThe SRSSRSDownload free working copies at:Download free working copies at:http://www.heartandsoulofchange.comhttp://www.heartandsoulofchange.com
  35. 35. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 35Improving or NotTwo Choices: Not Rocket ScienceImproving or NotTwo Choices: Not Rocket Science PCOMS simply identifies PCOMS simply identifies PCOMS simply identifiesclients who are notresponding so that the lackof progress can beaddressed in a positive,proactive way that keeps PCOMS simply identifiesclients who are notresponding so that the lackof progress can beaddressed in a positive,proactive way that keepsproactive way that keepsclients engaged whiletherapists collaborativelyseek new directionsproactive way that keepsclients engaged whiletherapists collaborativelyseek new directions Feedback v TAU; Feedback v TAU;Becoming BetterIsn’t It Good, Norwegian WoodBecoming BetterIsn’t It Good, Norwegian WoodBoth persons reliableor sig. change—50.5% v. 22.6%;ES: .50; 4 xs # ofli i hBoth persons reliableor sig. change—50.5% v. 22.6%;ES: .50; 4 xs # ofli i hclin. sig. change FU: TAU-34.2% v.18.4% Feedbacksep./divorce rateclin. sig. change FU: TAU-34.2% v.18.4% Feedbacksep./divorce rateAnker, M., Duncan, B., & Sparks, J. (2009). Using client feedback toimprove couple therapy outcomes: A randomized clinical trial in anaturalistic setting. Journal of Consulting and Clinical Psychology,77(4), 693-704.
  36. 36. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 36Barry Finds the Spot in the Norway PictureBy CoincidenceReese, Norsworthy, & Rowlands (2009)Reese, Toland, Slone, & Norsworthy, 2010Reese, Norsworthy, & Rowlands (2009)Reese, Toland, Slone, & Norsworthy, 2010 N=148: Feedback groupd bl d t l (10 4 N=148: Feedback groupd bl d t l (10 4Reese, R., Norsworthy, L., &Ro lands S (2009) Does adoubled controls (10.4vs. 5.1 pts); ES: .48 Like Norway study,clients, regardless of riskt t b fit fdoubled controls (10.4vs. 5.1 pts); ES: .48 Like Norway study,clients, regardless of riskt t b fit fRowlands, S. (2009). Does acontinuous feedback modelimprove psychotherapyoutcomes? Psychotherapy,46,418-431.Reese, R., Toland, M., Slone, N.,& Norsworthy, L. (2010). Effectof client feedback on couplepsychotherapy outcomes.status, benefit fromcontinuous feedback 2010 study is replicationof Norway Trialstatus, benefit fromcontinuous feedback 2010 study is replicationof Norway Trialpsychotherapy outcomes.Psychotherapy, 47, 616-630.
  37. 37. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 37Meta-analysis by Lambert & Shimokawa (2011)of PCOMS (the ORS and SRS)Those in feedback group had3.5 higher odds of experiencingreliable changeThose in feedback group had lessthan half the odds of experiencingdeteriorationdeteriorationFeedback attained .48 ESLambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48,72-79.Cooper, Stewart, Sparks, &Bunting, 2012Cooper, Stewart, Sparks, &Bunting, 2012 Benchmark study of 2887 11 ld t k Benchmark study of 2887 11 ld t k7-11 yr olds; caretaker-228; teacher-249; 11counselors; 28 schools7-11 yr olds; caretaker-228; teacher-249; 11counselors; 28 schools 2 fold advantage overchildren not usingfeedback as measuredon the SDQ 2 fold advantage overchildren not usingfeedback as measuredon the SDQ
  38. 38. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 38Two More in the WorksVeterans and YouthSubmitted: RCT Comparison of Schuman, D., Slone, N.,Duncan, B., & Reese, J. (2013).returning Afghanistan and IraqVets in group tx for substanceabuse; improved outcomes onthe ORS, clinician & Commanderratings; & reduced drop outsUsing client feedback toimprove outcomes withIraq/Afghanistan veterans.Gillaspy, A. Murphy, J., &Duncan, B., Bohankse, &Zatoga, A. (in process clinicaltrial). Using client feedback toimprove school interventiono tcomesCompletes in June: RCT ofintervention in the schools withchildren and adolescents withbehavioral problemsoutcomes.Effects on EfficiencyCancellations, No Shows, LOSEffects on EfficiencyCancellations, No Shows, LOS Claud (reported in Bohanske &Franczak) compared ave. # of Claud (reported in Bohanske &Franczak) compared ave. # ofFranczak) compared ave. # ofsessions, canc., no shows, and % oflong-term cases before and after OMin 2130 closed cases in a CMHC. Ave. # of sessions dropped 40% (10to 6) while outcomes improved by7% d h tFranczak) compared ave. # ofsessions, canc., no shows, and % oflong-term cases before and after OMin 2130 closed cases in a CMHC. Ave. # of sessions dropped 40% (10to 6) while outcomes improved by7% d h t7%; canc. and no show rates werereduced by 40% and 25%; and % oflong term null cases diminished by80% (10% to 2%). An estimated savings of $489,600.7%; canc. and no show rates werereduced by 40% and 25%; and % oflong term null cases diminished by80% (10% to 2%). An estimated savings of $489,600.Bohanske, R., & Franczak, M. (2010).Transforming public behavioral healthcare: Acase example of consumer directed services,recovery, and the common factors. In B.Duncan et al. (Eds.) The Heart and Soul ofChange: Delivering What Works, 2nd Ed.Washington, DC: AmericanPsychological Association.
  39. 39. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 39President Kennedy Signed the Mental Health Act on Oct31, 1963: Last Legislative Act Before the Assassination•NoteworthyVery Little Is Known about the PoorNon-Insured, and Designated DisabledVery Little Is Known about the PoorNon-Insured, and Designated DisabledNoteworthybecause 61% ofmental health andsubstance abusefis publicly funded.•What we doknow, news is bad
  40. 40. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 40Reported a combined reliableand clinically significant changePerhaps the Most Damning Data:Hansen, Lambert, and Forman (2002)and clinically significant changerate in CMHC of just 29.1%.70% not helpedOnly confirms the conclusionreached by the PNFCMH:y“America’s mental healthservice delivery system is inshambles [and] …incapable ofefficiently delivering…effectivetreatments. ” YIKES!!!!!!!For those receiving,Casts A Dim Shadow on Outcomes inPBH and Raises A Specific Questionproviding, or funding PBH,the question is not whethertherapy works but rather dothe benefits of therapyroutinely provided on theroutinely provided on thefront lines extend to theimpoverished,disempowered, &disenfranchised?
  41. 41. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 41Southwest Behavioral HealthPublic Behavioral HealthReese, Duncan,B h k O &Bohanske, Owen, &Minami, 2013:PBH achievedoutcomescomparable tocomparable toRCTs of depressionand feedback.How? PCOMSBecoming BetterRecapture Your At Risk ClientsBecoming BetterRecapture Your At Risk ClientsFeedback tailors servicesFeedback tailors services Feedback tailors servicesbased on response,provides an early warningsystem to prevents drop-outs & negative outcomes, Feedback tailors servicesbased on response,provides an early warningsystem to prevents drop-outs & negative outcomes,g ,& solves helpervariability—feedbackimproves performanceg ,& solves helpervariability—feedbackimproves performance
  42. 42. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 42In Fact, Client BasedOutcome FeedbackIn Fact, Client BasedOutcome Feedback Improves Improves Improvesoutcomesmore thananythingi th Improvesoutcomesmore thananythingi thsince thebeginning oftherapysince thebeginning oftherapyFeedback As A Common FactorFeedback As A Common Factor Overlaps with & affects allfactors tie that binds Overlaps with & affects allfactors tie that bindsfactors—tie that binds Soliciting feedback is aliving, process that engagesclients in monitoringoutcome, heightens hope,factors—tie that binds Soliciting feedback is aliving, process that engagesclients in monitoringoutcome, heightens hope,, g p ,fits client preferences,maximizes therapist-clientfit, and is itself a corefeature of change., g p ,fits client preferences,maximizes therapist-clientfit, and is itself a corefeature of change.
  43. 43. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 43And…FinallyAnd…Finally Puts the client’s voicet t Puts the client’s voicet tcenter stage Allows services to beclient and family driven Brings consumers intothe inner circle ofcenter stage Allows services to beclient and family driven Brings consumers intothe inner circle ofthe inner circle ofdecisions Partners in monitoringthe benefit and fit ofservicesthe inner circle ofdecisions Partners in monitoringthe benefit and fit ofservicesSkill BuildingBecoming Outcome InformedSkill BuildingBecoming Outcome Informed3 Skills of Outcome3 Skills of OutcomeInformed Practice (TheThree I’s) Introducing theMeasures Integrating ClientInformed Practice (TheThree I’s) Introducing theMeasures Integrating Client Integrating ClientFeedback into Practice Informing and TailoringServices Based on ClientFeedback Integrating ClientFeedback into Practice Informing and TailoringServices Based on ClientFeedback
  44. 44. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 44First Things FirstWhy You Might Be ReluctantFirst Things FirstWhy You Might Be Reluctant Finding out is risky Finding out is risky What if you find out thatyou are not so good? Whatif you are in the wrongprofession? The only way we improve What if you find out thatyou are not so good? Whatif you are in the wrongprofession? The only way we improve The only way we improveis thru feedback. It takescourage. But so doeswalking in a room withsomeone in distress. The only way we improveis thru feedback. It takescourage. But so doeswalking in a room withsomeone in distress. Norway: 9 of 10 got Norway: 9 of 10 gotRegarding Therapist VariabilityFeedback Improves OutcomesRegarding Therapist VariabilityFeedback Improves Outcomesy gbetter outcomes Feedback raisedeffectiveness of the lowerones to their moref l lly gbetter outcomes Feedback raisedeffectiveness of the lowerones to their moref l llsuccessful colleagues. Therapist in loweffectiveness groupbecame BEST w/feedback!successful colleagues. Therapist in loweffectiveness groupbecame BEST w/feedback!
  45. 45. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 45Counselors OutcomesProvider VariationFeedback Improves EffectivenessProvider VariationFeedback Improves Effectiveness(n=30 or more case s)0 20.40.60.811.21.41.61.8EffectsizeM ean Effect S ize for all Cases00.21(n=94)2(n=74)3(n=67)4(n=65)5(n=59)6(n=58)7(n=55)8(n=50)9(n=48)10(n=48)11(n=47)12(n=47)13(n=41)14(n=41)15(n=40)16(n=39)17(n=37)18(n=35)19(n=34)20(n=31)21(n=31)22(n=30)CounselorMiller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005). The Partners for ChangeMiller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005). The Partners for ChangeOutcome Management System.Outcome Management System. Journal of Clinical Psychology, 61Journal of Clinical Psychology, 61(2), 199(2), 199--208.208.Many BelieveThey Already KnowMany BelieveThey Already Know The info the measuresreveal that are attuned to The info the measuresreveal that are attuned toreveal—that are attuned toclient’s experience & theforms superfluous. Norway study: all believedthey already acquiredoutcome & alliance info—thatreveal—that are attuned toclient’s experience & theforms superfluous. Norway study: all believedthey already acquiredoutcome & alliance info—thatoutcome & alliance info thatformal feedback wouldn’timprove their effectiveness. 9 of 10 improved; only 1correct.outcome & alliance info thatformal feedback wouldn’timprove their effectiveness. 9 of 10 improved; only 1correct.
  46. 46. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 46 You might be thinking You might be thinkingFirst Things FirstWhy You Might Be ReluctantFirst Things FirstWhy You Might Be Reluctantthat you need morepaperwork like a hole inthe head. Helpers canget really worked upthat you need morepaperwork like a hole inthe head. Helpers canget really worked upover anything that addspaperwork, especiallywhen they don’t see itas clinically useful.over anything that addspaperwork, especiallywhen they don’t see itas clinically useful. Need not be cumbersome.O l l f i Need not be cumbersome.O l l f iFirst Things FirstWhy You Might Be ReluctantFirst Things FirstWhy You Might Be ReluctantOnly a couple of min., nointrusive ?s, internal to &meaningful to the work. Feedback the best hope toOnly a couple of min., nointrusive ?s, internal to &meaningful to the work. Feedback the best hope to Feedback the best hope toimprove, clients appreciateyour dedication to getting itright & you can fit into yournatural way of working. Feedback the best hope toimprove, clients appreciateyour dedication to getting itright & you can fit into yournatural way of working.
  47. 47. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 47Getting the Max Out of the MeasuresJust the Facts Ma’amGetting the Max Out of the MeasuresJust the Facts Ma’am The nuts & bolts & The nuts & bolts & The nuts & bolts, &the nuances, more toit, clinically, than itlooksF db k i h The nuts & bolts, &the nuances, more toit, clinically, than itlooksF db k i h Feedback is the wayto transcendaverage. Feedback is the wayto transcendaverage.Client Privilege and Social JusticeClients Have Been Missing PersonsClient Privilege and Social JusticeClients Have Been Missing PersonsDespite well-intentionedefforts, the infrastructure oftherapy (paperwork,policies, procedures, andprofessional language) canreify non-contextualizedreify non contextualizeddescriptions of clientproblems and silence clientviews, goals, andpreferences.
  48. 48. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 48The Measures and Social Justice“Leveling” the Counseling ProcessThe Measures and Social Justice“Leveling” the Counseling Process Invites clients into inner Invites clients into innercircle of decision making Available in multiplelanguages Voice to diversity and thecircle of decision making Available in multiplelanguages Voice to diversity and theydisenfranchised Local culture and contextover privileged knowledgeydisenfranchised Local culture and contextover privileged knowledgeCli t’ ti f thti f thStarting WithStarting With the Predictorsthe PredictorsChange and the Alliance•Client’s rating of therating of thealliancealliance the best predictor ofthe best predictor ofengagement and outcome.engagement and outcome.•Client’s subjectivesubjectiveexperience of change earlyexperience of change earlyexperience of change earlyexperience of change earlyin the process the bestin the process the bestpredictor of success for anypredictor of success for anyparticular pairing.particular pairing.
  49. 49. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 49Who drops out?Sooner Rather Than LaterAB•The bulk ofchangeoccurs soonerrather thanHoward, K. et al. (1986). The dose-effect response in psychotherapy.American Psychologist, 41, 159-164.rather thanlatterSome clients do takelonger, but the mythologynever diesN=4676; 77% attended 8or less, and 91% 12 or lessNote that even for theclients who take longer(last curve bottom right)Baldwin, S., Berkeljon, A., Atkins, D., Olsen, J., & Nielsen, S. (2009). Rates of change in naturalisticpsychotherapy: Contrasting dose-effect and good-enough level models of change. Journal ofConsulting and Clinical Psychology, 77(2), 203-211.(last curve bottom right),change starts early…just isflatter
  50. 50. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 50Cannabis Youth Treatment ProjectEarly change inIt’s A FactEarly Change is The RuleProject MATCHy gtreatment is arobust predictorof outcome andretention intreatmenthttp://www.chestnut.org/LI/Posters/CYT_%20MF_APA.pdfBabor, T.F., & DelBoca, F.K. (eds.) (2003). TreatmentMatching in Alcoholism. United Kingdom: Cambridge, 113.treatment.Gotta measureoutcome!The Rule: Treatment of DepressionCollaborative Research ProgramThe Rule: Treatment of DepressionCollaborative Research ProgramTDCRPConclusions: Early change is an important factor for theprediction of short- and long-term outcome.Lutz, W., Stulz, N., & Köck, K. (2009). Patterns of early change and their relationship to outcome and follow-upamong patients with major depressive disorders. Journal of Affective Disorders 118(1), 60-68.
  51. 51. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 51••Give at theGive at theBecoming BetterMeasuring OutcomeBecoming BetterMeasuring Outcome••Scored to theScored to thenearest millimeter.nearest millimeter.••Add the fourAdd the fourscales togetherscales together••Give at theGive at thebeginning of thebeginning of thevisit; Clientvisit; Clientplaces a markplaces a markon the line.on the line.••Each line 10Each line 10(100 ) i(100 ) iscales togetherscales togetherfor the total score.for the total score.cm (100 mm) incm (100 mm) inlength.length.•Reliable, valid,feasibleThe ORS Is Not ThisThe ORS Is Not This
  52. 52. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 52The ORS Is Different ThanOther Outcome MeasuresThe ORS Is Different ThanOther Outcome Measures Co-constructed withclient Co-constructed withclientclient Goes from generallook at client distressto specificrepresentation ofclient Goes from generallook at client distressto specificrepresentation ofpclient’s experience &reason for service Requires nuance &skill in applicationpclient’s experience &reason for service Requires nuance &skill in application•When scheduling, provideBecoming BetterCreating A Culture of FeedbackBecoming BetterCreating A Culture of Feedbackrationale for seeking feedback;convey commitment to their goalsand highest quality of service…inyour own words•Work a little differently;•If we are going to be helpful•If we are going to be helpfulshould see signs sooner ratherthan later; If not helpful, we’ll seekconsultation & consider a referral.•No one has ever said: Bad idea!
  53. 53. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 53The Outcome Rating ScaleAn Introduction in Your Own WordsThe Outcome Rating ScaleAn Introduction in Your Own Words The ORS is an outcome measure that allowst t k h ’ t h ’ d i The ORS is an outcome measure that allowst t k h ’ t h ’ d ius to track where you’re at, how you’re doing,how things are changing or if they are not. Itallows us to determine whether the counselingis being helpful so we can do somethingdifferent if it’s not helping. It also is way tomake sure that your perspective stays centralh th t dd i h t thi k ius to track where you’re at, how you’re doing,how things are changing or if they are not. Itallows us to determine whether the counselingis being helpful so we can do somethingdifferent if it’s not helping. It also is way tomake sure that your perspective stays centralh th t dd i h t thi k ihere, that we are addressing what you think ismost important. It only takes a minute to fillout and most clients find it to be very helpful.Would you like to give it a try?here, that we are addressing what you think ismost important. It only takes a minute to fillout and most clients find it to be very helpful.Would you like to give it a try?The First SessionWhatever It TakesThe First SessionWhatever It Takes You can’t over-explain… You can’t over-explain… Clients get this. Face validity. Whatever explanation theclient gives is ok. Some willsay: “You mean like poor towell?” or “Like 1 to 10?” Clients get this. Face validity. Whatever explanation theclient gives is ok. Some willsay: “You mean like poor towell?” or “Like 1 to 10?”well? or Like 1 to 10? It’s their subjectiveexperience that matters sotheir understanding of themeasure is paramount.well? or Like 1 to 10? It’s their subjectiveexperience that matters sotheir understanding of themeasure is paramount.
  54. 54. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 54The First MeetingIntroducing the ORSThe First MeetingIntroducing the ORS Introduce the ORSi Introduce the ORSiusing your ownwords—convey thenotion of monitoringoutcome and ensuringclient voice is heardusing your ownwords—convey thenotion of monitoringoutcome and ensuringclient voice is heardclient voice is heard Measure the marksand add the scoresclient voice is heard Measure the marksand add the scoresThe First MeetingThe “Clinical Cutoff”The First MeetingThe “Clinical Cutoff”40••The dividing lineThe dividing line510152025303540OutcomeScorebetween a clinical &between a clinical &“non“non--clinical”clinical”population (25). Forpopulation (25). Forchildren (32children (32);); adolsadols(28) t k (28)(28) t k (28)051st 2nd 3rd 4thSessionNumberActual Score Line 2 25th% 75th%(28); caretakers (28)(28); caretakers (28)••BetweenBetween 2020--30%30%score in the “nonscore in the “non--clinical” range.clinical” range.
  55. 55. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 55The Clinical CutoffOnly 2 ChoicesThe Clinical CutoffOnly 2 Choices Either above or below.M ti li t it Either above or below.M ti li t it Mention client score as itrelates to the cutoff & havethe client make sense of it. Scores under cutoff mayseem more straightforward Mention client score as itrelates to the cutoff & havethe client make sense of it. Scores under cutoff mayseem more straightforward Reporting distress similar toothers seeking services—the lower the score, thehigher the distress. Lookingfor a change. Reporting distress similar toothers seeking services—the lower the score, thehigher the distress. Lookingfor a change.40Initial Information…Initial Information…••Client’s scoreClient’s score102030ORSscoreClient s scoreClient s scoreis withinis within thetheclinical range.clinical range.••Scoring moreScoring morelike people inlike people in01 2 3 4 5 6 7 8 9 10Session numberProjected change 75th percentile ORS ScoresEstimated Clinical Cutoff 25th percentiletherapy andtherapy andwantingwantingsomething tosomething tochangechange
  56. 56. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 56ORS: An ExampleORS: An Example••What can we gleanWhat can we glean7.65.78.0What can we gleanWhat can we gleanclinicallyclinically from thisfrom thisclient’s scores inclient’s scores inaddition to being aboveaddition to being abovethe clinical cut off?the clinical cut off?7.5Total =Total = 28.828.8••How could we use thisHow could we use thisinformation to begin orinformation to begin orfocus the session?focus the session?••Explore why the client enteredExplore why the client enteredThe First MeetingOver the Clinical CutoffThe First MeetingOver the Clinical Cutoffxplo e why the client ente edxplo e why the client ente edtherapy; circumscribedtherapy; circumscribed problem orproblem ormandated/coercedmandated/coerced••If mandated, ask for the referral’sIf mandated, ask for the referral’srating as a catalyst forrating as a catalyst forconversation; doesn’tconversation; doesn’t mean they aremean they areconversation; doesn tconversation; doesn t mean they aremean they arelyinglying••AvoidAvoid stirring the cauldronstirring the cauldron
  57. 57. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 57Take Clients at Face ValueTake Clients at Face Value Please don’t interpret high Please don’t interpret highscores as a misrepresentation It is the way the client seeshim or herself They don’t have to see aproblem for therapy to helpscores as a misrepresentation It is the way the client seeshim or herself They don’t have to see aproblem for therapy to helpproblem for therapy to help Other’s ratings important too Just because it’s high doesn’tmean they won’t engageproblem for therapy to help Other’s ratings important too Just because it’s high doesn’tmean they won’t engageFirst Session: Connect ORS to theClient’s Described ExperienceFirst Session: Connect ORS to theClient’s Described Experience At some point,connect the client’sdescribed experienceof their lives to the At some point,connect the client’sdescribed experienceof their lives to theof their lives to themarks on the scalesof their lives to themarks on the scales
  58. 58. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 58The ORSThe Bare BonesThe ORSThe Bare Bones No specific content otherth d i k l t t No specific content otherth d i k l t tthan domains—a skeleton towhich clients add the flesh &blood of their experiences. At the moment clientsconnect the marks with whatthan domains—a skeleton towhich clients add the flesh &blood of their experiences. At the moment clientsconnect the marks with whatconnect the marks with whatthey find distressing, the ORSbecomes a meaningfulmeasure of their progressand potent clinical tool.connect the marks with whatthey find distressing, the ORSbecomes a meaningfulmeasure of their progressand potent clinical tool. Has to beR l h Has to beR l hIntegrating the MeasuresProblems and Challenges?Relevant to theWork Or Becomes anRelevant to theWork Or Becomes an Or Becomes anEmotionalThermometer ofDay to Day Life Or Becomes anEmotionalThermometer ofDay to Day Life
  59. 59. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 59Get A Good RatingMake SureGet A Good RatingMake SureT thT th Transparency therule, notconfrontation/judgment Transparency therule, notconfrontation/judgment Darrell and AngelinaJolie Darrell and AngelinaJolie40 Years of Data say…40 Years of Data say…•Client’s rating of therating of thealliancealliance the best predictor ofthe best predictor ofengagement and outcomeengagement and outcome..•Client’s subjective experiencesubjective experienceof change early in the processof change early in the processthe best predictor of successthe best predictor of successfor any particular pairing.for any particular pairing.
  60. 60. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 60Clients drop out for 2Quickest WayPrevent Drop OutQuickest WayPrevent Drop OutClients drop out for 2reasons: counseling is nothelping (monitor outcome) &alliance problems—notengaged or turned on. Directway to improve effectiveness isway to improve effectiveness isto keep people engaged intherapy.Gotta measure the allianceThe Session Rating ScaleMeasuring the AllianceThe Session Rating ScaleMeasuring the Alliance••Give at the endGive at the endof session;of session;••Score in cm toScore in cm tothe nearest mm;the nearest mm;••Each line 10 cmEach line 10 cmin length;in length;•Reliable, valid,feasible••Discuss withDiscuss withclient anytimeclient anytimetotal score fallstotal score fallsbelowbelow 3636
  61. 61. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 61Becoming BetterA Culture of Feedback with the SRSBecoming BetterA Culture of Feedback with the SRS•When scheduling a firstappointment, provide a rationalepp pfor seeking feedback regarding thealliance.•Work a little differently;•Want to make sure that you aregetting what you need;•Take the “temperature” at the end ofeach visit;each visit;•Feedback is critical to success.•Restate the rationale prior toadministering the scale.•How not to do the SRSMake My DayMake My Day
  62. 62. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 62The Session Rating ScaleAn Introduction in Your Own WordsThe Session Rating ScaleAn Introduction in Your Own Words Let’s take a minute and have you fill out theth f th t k i i b t Let’s take a minute and have you fill out theth f th t k i i b tother form that asks your opinion about ourwork together. It’s kind of like taking thetemperature of our relationship today. Arewe too hot or too cold? Do I need to adjustthe thermostat? This information helps mestay on track. The ultimate purpose of usingth f i t k ibl ff tother form that asks your opinion about ourwork together. It’s kind of like taking thetemperature of our relationship today. Arewe too hot or too cold? Do I need to adjustthe thermostat? This information helps mestay on track. The ultimate purpose of usingth f i t k ibl ff tthese forms is to make every possible effortto make our work together beneficial. Ifsomething is amiss, you would be doing methe best favor if you let me know. Can youhelp me out?these forms is to make every possible effortto make our work together beneficial. Ifsomething is amiss, you would be doing methe best favor if you let me know. Can youhelp me out?
  63. 63. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 63The Session Rating ScaleTraditionallyThe Session Rating ScaleTraditionally Told us with their feetWill let s kno on SRS Told us with their feetWill let s kno on SRS Will let us know on SRSbefore telling/bolting. Takes work for candor. Disparity in power &socio- economic, ethnic, Will let us know on SRSbefore telling/bolting. Takes work for candor. Disparity in power &socio- economic, ethnic,, ,or racial diff., can makeit tough. When was thelast time you told yourphysician, “Youremaking a big mistake"?, ,or racial diff., can makeit tough. When was thelast time you told yourphysician, “Youremaking a big mistake"?But Don’t StressIt’s OkayBut Don’t StressIt’s Okay Keep encouraging client tolet you know Keep encouraging client tolet you knowlet you know… Have to KNOW: No badnews. Not a measure ofcompetence or anythingnegative about you or theclient. Gift from the clientth t h l t b b ttlet you know… Have to KNOW: No badnews. Not a measure ofcompetence or anythingnegative about you or theclient. Gift from the clientth t h l t b b ttthat helps you to be better. Unless you really want it,you are unlikely to get it. You won’t get it fromeveryone.that helps you to be better. Unless you really want it,you are unlikely to get it. You won’t get it fromeveryone.
  64. 64. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 64The Session Rating ScaleA Quick Visual CheckThe Session Rating ScaleA Quick Visual Check Scores < 36 or 9cms should Scores < 36 or 9cms shouldbe discussed. SRS is good or its not. Eitherthank the client for thefeedback, & invite them toshare future concerns; orbe discussed. SRS is good or its not. Eitherthank the client for thefeedback, & invite them toshare future concerns; orshare future concerns; orthank client & explore whytheir ratings are lower sothat you can fix the concern. Building the Allianceshare future concerns; orthank client & explore whytheir ratings are lower sothat you can fix the concern. Building the AllianceThe Session Rating ScaleWhat About Below 36 or 9cm?The Session Rating ScaleWhat About Below 36 or 9cm? Don’t expect specificso e elations an Don’t expect specificso e elations anor revelations—anyfeedback is a godsend Is there anything else Icould have done,something I shouldor revelations—anyfeedback is a godsend Is there anything else Icould have done,something I shouldsomething I shouldhave done more of orless of, some questionor topic I should haveasked?something I shouldhave done more of orless of, some questionor topic I should haveasked?
  65. 65. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 65The SRSGraceful AcceptanceThe SRSGraceful Acceptance And a willingness to be flexiblell t thi d And a willingness to be flexiblell t thi dusually turn things around. Clients reporting allianceproblems more likely forsuccess. Lower scores on theSRS should be celebrated.usually turn things around. Clients reporting allianceproblems more likely forsuccess. Lower scores on theSRS should be celebrated.SRS should be celebrated. If clients are comfortableenough to express somethingisn’t right, then you are doingsomething great.SRS should be celebrated. If clients are comfortableenough to express somethingisn’t right, then you are doingsomething great.XXXXNow we’re ready to be better at what we doybut first we must heed the words of a notedpsychotherapy scholar
  66. 66. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 66Granted at firstSage Psychotherapy Scholar:Mae West?Granted, at firstblush, thesehardly seem likewords for us tolive by—but, asWhen I’mgood,I’m verygood,b t hen live by but, asit turns out, theyare.but whenI’m bad,I’m better.Becoming BetterHelping Every Single ClientBecoming BetterHelping Every Single Client When clients are not When clients are not When clients are notbenefiting provides theopportunity to do yourbest work—gives youthe possibility of being When clients are notbenefiting provides theopportunity to do yourbest work—gives youthe possibility of beingthe possibility of beinghelpful to everyone yousee. Sound too good tobe true? It’s not.the possibility of beinghelpful to everyone yousee. Sound too good tobe true? It’s not.
  67. 67. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 67Becoming BetterIdentifying Clients Not RespondingBecoming BetterIdentifying Clients Not Responding When outcome is badi h d When outcome is badi h din other words, youcan make it better bychanging somethingabout the therapy toturns things around;in other words, youcan make it better bychanging somethingabout the therapy toturns things around;turns things around;and if things don’t turnaround, by moving theclient on to a differentprovider or serviceturns things around;and if things don’t turnaround, by moving theclient on to a differentprovider or serviceBecoming BetterTwo Choices: Not Rocket ScienceBecoming BetterTwo Choices: Not Rocket Science Either the client isi i t If t Either the client isi i t If timproving or not. If not,the client is at risk. Engage client in discussionabout progress, and whatshould be done differentlyimproving or not. If not,the client is at risk. Engage client in discussionabout progress, and whatshould be done differentlyshould be done differentlyif there isn’t any. Keeps clients engaged sothat a new direction can beplanned.should be done differentlyif there isn’t any. Keeps clients engaged sothat a new direction can beplanned.
  68. 68. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 68Becoming BetterWhen I’m Good, I’m Very GoodBecoming BetterWhen I’m Good, I’m Very Good When ORS scores When ORS scoresincrease, when you’regood, a crucial step tobe very good is helpclients see gains as aconsequence of theirincrease, when you’regood, a crucial step tobe very good is helpclients see gains as aconsequence of theirconsequence of theirown efforts and makesense of its meaningso repeat in thefuture.consequence of theirown efforts and makesense of its meaningso repeat in thefuture.Becoming BetterLinking Outcome to LOS••See clientsSee clients moremorefrequently when thefrequently when thefrequently when thefrequently when theslope of change isslope of change issteep.steep.••Begin to space theBegin to space thevisits as the rate ofvisits as the rate ofchange lessens.change lessens.gg••See clients as longSee clients as longas there isas there ismeaningful changemeaningful change& they desire to& they desire tocontinue.continue.
  69. 69. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 69Becoming BetterDoesn’t Mean All Therapy Should Be BriefBecoming BetterDoesn’t Mean All Therapy Should Be Brief Au contraire, researchh i Au contraire, researchh isuggests that more isbetter than less forclients who progressearly & want to continue. When little or changesuggests that more isbetter than less forclients who progressearly & want to continue. When little or change When little or change,however, same dataindicates that therapyshould, indeed, be asbrief as possible. When little or change,however, same dataindicates that therapyshould, indeed, be asbrief as possible. Involve the client in Involve the client inBecoming BetterWhat to Do NextBecoming BetterWhat to Do Nextmonitoring progress & thedecision about what to donext, to elicit his or her ideas& formulate a plan. The discussion repeated in allmonitoring progress & thedecision about what to donext, to elicit his or her ideas& formulate a plan. The discussion repeated in all The discussion repeated in allmeetings, but later ones gainsignificance and warrantadditional action: Checkpointand Last Chance Discussions. The discussion repeated in allmeetings, but later ones gainsignificance and warrantadditional action: Checkpointand Last Chance Discussions.
  70. 70. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 70 Okay, so things haven’t changed since Okay, so things haven’t changed sinceBecoming BetterClient Not ImprovingBecoming BetterClient Not Improvingthe last time we talked. How do youmake sense of that? Should we be doingsomething different here, or should wecontinue on course steady as we go? Ifthe last time we talked. How do youmake sense of that? Should we be doingsomething different here, or should wecontinue on course steady as we go? Ifwe are going to stay on the same track,how long should we go before gettingworried? When will we know when to say“when?”we are going to stay on the same track,how long should we go before gettingworried? When will we know when to say“when?”Becoming BetterWhen to Say WhenBecoming BetterWhen to Say When Stimulates both clientd th i t t Stimulates both clientd th i t tand therapist tostruggle withcontinuing a processthat is yielding little orno benefit.and therapist tostruggle withcontinuing a processthat is yielding little orno benefit. To support what isworking & challengewhat is not. Urgencyincreases over time To support what isworking & challengewhat is not. Urgencyincreases over time
  71. 71. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 71Checkpoint Session:An Opportunity to Be BetterCheckpoint Session:An Opportunity to Be BetterB t tB t t Be transparent—comment about thelack of progress andseek feedback from Be transparent—comment about thelack of progress andseek feedback fromthe client about whathe/she thinks it meansthe client about whathe/she thinks it meansBecoming BetterFirst, the AllianceBecoming BetterFirst, the Alliance “It doesn’t look like we are “It doesn’t look like we aregetting anywhere. Let’s goover the SRS to make sureyou are getting exactlywhat you are looking for.”Going thru SRS and elicitinggetting anywhere. Let’s goover the SRS to make sureyou are getting exactlywhat you are looking for.”Going thru SRS and elicitingg gclient responses in detailcan help you & the clientget a better sense of whatmay not be working.g gclient responses in detailcan help you & the clientget a better sense of whatmay not be working.
  72. 72. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 72Checkpoint ConversationDo Something DifferentCheckpoint ConversationDo Something Different Nothing may come of talkabout the alliance Don’t Nothing may come of talkabout the alliance Don’tabout the alliance. Don tworry. Making effort helps. Invite others from supportsystem, use a team or co-therapist, a differentapproach; referral to anotherabout the alliance. Don tworry. Making effort helps. Invite others from supportsystem, use a team or co-therapist, a differentapproach; referral to anotherpphelper, religious advisor, orself-help group—whateverseems of value. Any ideas are implemented,and progress is monitored.pphelper, religious advisor, orself-help group—whateverseems of value. Any ideas are implemented,and progress is monitored.Becoming BetterThe Last Chance DiscussionBecoming BetterThe Last Chance Discussion Driving into desert Driving into desertgrunning on empty,“last chance for gas.” Depicts the necessityof stopping anddiscussing thegrunning on empty,“last chance for gas.” Depicts the necessityof stopping anddiscussing thediscussing theimplications ofcontinuing w/ochange.discussing theimplications ofcontinuing w/ochange.
  73. 73. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 73Becoming BetterNever the LAST CHANCEBecoming BetterNever the LAST CHANCE Doesn’t mean the“last chance” fo Doesn’t mean the“last chance” fo“last chance” foryour client—butrather the lastchance of a changeplan or pairing. No“last chance” foryour client—butrather the lastchance of a changeplan or pairing. Nop p glast chance for yourclient—referral canmake thedifference!p p glast chance for yourclient—referral canmake thedifference!1.What does the client say?Last Chance ThoughtsThe Longer w/o Change, the Quicker to #52.What have you donedifferently?3.What can be donedifferently now?4 Wh t th4.What other resources canbe rallied?5.Is it time to failsuccessfully?
  74. 74. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 74Becoming BetterHelping Every Single ClientBecoming BetterHelping Every Single Client All clients can’t benefit. Stillt b h l f l All clients can’t benefit. Stillt b h l f la way to be helpful. Might have felt like afailure. But when I’m bad,I’m better. Now successfulh li t hia way to be helpful. Might have felt like afailure. But when I’m bad,I’m better. Now successfulh li t hiwhen client achieveschange & when, in theabsence of change, I getout of the way.when client achieveschange & when, in theabsence of change, I getout of the way.Becoming BetterThe Last Chance DiscussionBecoming BetterThe Last Chance Discussion At the least, consultation At the least, consultation Referral seriously discussed. Rarely justified to continuepast typical period. Rarely is not never. Highlyidi ti & i l Referral seriously discussed. Rarely justified to continuepast typical period. Rarely is not never. Highlyidi ti & i lidiosyncratic & uniquelynegotiated. Keeps us honest,addresses the lack of changetransparently—new for me.idiosyncratic & uniquelynegotiated. Keeps us honest,addresses the lack of changetransparently—new for me.
  75. 75. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 75When I’m Bad, I’m BetterFailing SuccessfullyWhen I’m Bad, I’m BetterFailing Successfully Repeat commitment to Repeat commitment tophelp them achieve goals. Failure says nothingabout them or theirpotential. If client wants, meet untilphelp them achieve goals. Failure says nothingabout them or theirpotential. If client wants, meet until If client wants, meet untilarrangements are made. But rarely continue withclients who show noimprovement. If client wants, meet untilarrangements are made. But rarely continue withclients who show noimprovement.100My Data405060708090Percentreaching%98%01020301 2 3 4 5 6 7target75%
  76. 76. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 76Failing SuccessfullyFailing SuccessfullyChange of TherapistWatershed ClientFailing SuccessfullyWatershed ClientFailing Successfully I believed in PBE, but… I believed in PBE, but…I wish my helper hadfailed successfully Awakened me to thepitfalls; taught me to failsuccessfully. Avoid a “chronic” client—the iatrongenic effects of Awakened me to thepitfalls; taught me to failsuccessfully. Avoid a “chronic” client—the iatrongenic effects ofthe iatrongenic effects ofcontinuing therapy w/obenefit. ORS allows us to askourselves hard questions.the iatrongenic effects ofcontinuing therapy w/obenefit. ORS allows us to askourselves hard questions.
  77. 77. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 77Becoming BetterGuard Against Finger PointingBecoming BetterGuard Against Finger Pointing Guard against explainingli t th Guard against explainingli t thclient response thrutheoretical filters &folklore— puts us rightback where we havetraditionally been—attributing lack of changeclient response thrutheoretical filters &folklore— puts us rightback where we havetraditionally been—attributing lack of changeattributing lack of changeto the client. Client non-response meanssomething else should bedone.attributing lack of changeto the client. Client non-response meanssomething else should bedone.Becoming BetterFeedback Is My CompassBecoming BetterFeedback Is My Compass Not an uninhabited terrain oftechnical procedures, nor the Not an uninhabited terrain oftechnical procedures, nor thep ,predictable path of diagnosis,prescription, & cure. Cannot bedescribed w/o the client &therapist, co-adventurers in ajourney across unchartedterritory. Common factorsprovide landmarks for thisp ,predictable path of diagnosis,prescription, & cure. Cannot bedescribed w/o the client &therapist, co-adventurers in ajourney across unchartedterritory. Common factorsprovide landmarks for thisprovide landmarks for thisinterpersonal & idiosyncratic trip,& specific models provide well-traveled directions to consider,but feedback provides thecompass, showing the way tothe desired destination.provide landmarks for thisinterpersonal & idiosyncratic trip,& specific models provide well-traveled directions to consider,but feedback provides thecompass, showing the way tothe desired destination.
  78. 78. www.heartandsoulofchange.com April, 2013barrylduncan@comcast.net 78Being BadCan Make You BetterBeing BadCan Make You Better Helps clients you are alreadyff ti ith b i Helps clients you are alreadyff ti ith b ieffective with by empoweringchange—helps those notbenefiting by enabling otheroptions and, in absence ofchange, the ability to movethe client on.effective with by empoweringchange—helps those notbenefiting by enabling otheroptions and, in absence ofchange, the ability to movethe client on.the client on. When we’re good, we’revery good, but whenwe’re bad, we can beeven better.the client on. When we’re good, we’revery good, but whenwe’re bad, we can beeven better.What Separates The Best?Barry’s RecipeWhat Separates The Best?Barry’s Recipe 1. Client Feedback Improves 1. Client Feedback ImprovesOutcomes More than Anythingsince the Beginning ofPsychotherapy 2. Clients Account for Most ofthe Variance: Rally RecruitOutcomes More than Anythingsince the Beginning ofPsychotherapy 2. Clients Account for Most ofthe Variance: Rally Recruitthe Variance: Rally, RecruitHarvest Resources for Change 3. Rely on the Tried & TrueOld Friend, the Alliancethe Variance: Rally, RecruitHarvest Resources for Change 3. Rely on the Tried & TrueOld Friend, the Alliance

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