1                                                                                                                  n.     ...
else. My curiosity piqued, I was just about to ask what was going on when the        chief psychologist, a kindly old guy ...
a favor and help me out. The chief psychologist said, “Good approach,” and            walked off.1                   So Ti...
I just want to                                                                          help people!                      ...
Accounts by psychotherapists of their professional [work] suggest that the                   feelings they experience whil...
THE GOOD, THE BAD, AND THE UGLY                To exchange one orthodoxy for another is not necessarily an advance.       ...
psychotherapists did not identify 39 out of the 40 clients who deteriorated. In            contrast, the actuarial method ...
and present-centered therapy. A recent meta-analysis comparing these treat-        ments found all of them about equally e...
is nothing if not seductive as it teases our desires to be helpful. A treatment for            a specific “disorder,” from ...
pioneer Michael Lambert has conducted five RCTs and all five demonstrated        significant gains for feedback groups over t...
engaging at a high level of basic empathic and communication skills, con-                   scious of Flow-type feelings d...
at some point. Not therapists. They want to continue to get better throughout        their careers.               Second, ...
How does all this relate to client feedback? Tracking client responses to            therapy provides an accessible route ...
This ordeal miraculously inspired Ariely to research the experience of        pain as well as other phenomena. His investi...
as the myriad ways by which people transcend adversity and cope with the            unthinkable. With each session under o...
“Are you crazy, man? He is a simple farmer!” “No,” answered the first        researcher emphatically, “that man is a resea...
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
OnBecomingABetterTherapistCh1
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Chapter One of On Becoming a Better Therapist.

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  1. 1. 1 n. SO YOU WANT TO BE A tio bu BETTER THERAPIST tri is rD fo ot N d. ve er es R The only man I know who behaves sensibly is my tailor; he takes my s ht measurements anew each time he sees me. The rest go on with their old ig measurements and expect me to fit them. R —George Bernard Shaw ll n .A tio ia While I often don’t remember where I leave my glasses, I still vividly oc recall my first client, including her full name, but I’ll call her Tina. A long ss lA time ago in a galaxy far way, I was in my initial clinical placement in gradu- ca ate school at the Dayton Mental Health and Developmental Center, the gi state hospital in Ohio. This practicum was largely, if not totally, intended to lo be an assessment experience. After all, you don’t really do therapy with those ho folks, do you? Tina was like a lot of the clients: young, poor, disenfranchised, yc heavily medicated, and on the merry-go-round of hospitalizations—oh, and Ps similar to her fellow patients, at the ripe old age of 22, she was called a an “chronic schizophrenic.” ic er I gathered up my Wechsler Adult Intelligence Scale-Revised (WAIS), Am the first of the battery of tests I was attempting to gain competence with, and was on my merry but nervous way to the assessment office, a stark, run-down ht rig room in a long-past-its-prime, barrack-style building that reeked of cleaning y fluids overused to cover up some other worse smell, the institutional stench. Butop on the way I couldn’t help but notice all the looks I was getting—a smirk fromC an orderly, a wink from a nurse, and funny-looking smiles from nearly everyone 3 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  2. 2. else. My curiosity piqued, I was just about to ask what was going on when the chief psychologist, a kindly old guy (he was probably younger than I am now) who likely stayed in the state system long after he knew he should leave, put his hand on my shoulder and said, “Barry, you might want to leave the door open.” And I did. I greeted Tina, a young, extremely pale woman with short, brown, n. cropped hair (who might have looked a bit like Mia Farrow in the Rosemary’s tio Baby era had Tina lived in friendlier circumstances), and introduced myself bu in my most professional voice. Before I could sit down and open my test kit, tri is Tina started to take off her clothes, mumbling something indiscernible. I just rD stared in disbelief, in total shock really. Tina was undaunted by my dismay fo and quickly was down to her bra and underwear when I finally broke my ot silence, hearing laughter in the distance, and said, “Tina, what are you N doing?” Tina responded not with words but with actions, removing her bra d. ve like it had suddenly become very uncomfortable. So, there we were, a gradu- er ate student, speechless, in his first professional encounter, and a client sitting es nearly naked, mumbling now quite loudly but still nothing I could under- R stand, and contemplating whether to stand up to take her underwear off or s simply continue her mission while sitting. ht ig Finally, in desperation, I pleaded, “Tina, would you please do me a big R favor? I mean, I would really appreciate it.” She looked at me for the first time, ll .A looked me right in the eye, and said, “What?” I replied, “I would really be grate- n io ful if you could put your clothes back on and help me get through this assess- t ia ment. I’ve done them before, but never with a client, and I am kinda freaked oc out about it.” Tina whispered, “Sure,” and put her clothes back on. And ss although Tina struggled with the testing and clearly was not enjoying herself, lA she completed it. I was so genuinely appreciative of Tina’s help that I told her ca she really pulled me through my first real assessment. She smiled proudly, and gi lo ultimately smiled at me every time she saw me from then on. I wound up get- ho ting to know Tina pretty well and often reminded her how she helped me, yc and I even told her that I thought she looked like Mia Farrow, which she Ps immensely enjoyed. Every time she left the hospital, I hoped that I would an never see her again—but I did. ic Later that day, the chief psychologist caught up with me and asked me er how I got Tina to put her clothes back on and complete the WAIS. He added Am that others had either just walked out of the room or simply commanded Tina ht to put on her clothes. One time, he said, Tina responded aggressively to the rig commands and was put in restraints. The psychologist smiled a patronizing yop smile that said “someday you’ll understand” and reported that Tina was a sortC of rite of passage for the psychology trainees. In truth, I was angry but I didn’t say anything about that to him. I replied that all I did was to ask her to do me 4 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  3. 3. a favor and help me out. The chief psychologist said, “Good approach,” and walked off.1 So Tina started my psychotherapy journey and offered up my first les- sons for consideration: authenticity matters and when in doubt or in need of help, ask the client. Wherever you are, Tina, thanks for the great start. This book reflects these lessons and highlights the value of transparency and true n. partnerships with clients. tio I am a true believer in psychotherapy and in therapists of all stripes bu and flavors. In my 30 years and 17,000 hours of experience with clients, I tri is have been privileged to witness the irrepressible ability of human beings to rD transcend adversity—clients troubled by self-loathing and depression, bat- fo tling alcohol or drugs, struggling with intolerable marriages, terrorized by ot inexplicable voices, oppressed by their children’s problems, traumatized by N past or current life circumstances, and tormented with unwanted thoughts d. ve and anxieties—with amazing regularity. As a trainer and consultant, I have er rubbed elbows with thousands of psychotherapists across the globe, and the es thing that strikes me most is their authentic desire to be helpful. Regardless R of discipline, theoretical persuasion, or career level, they really care about s ht people and strive to do good work. The odds for change when you combine ig a resourceful client and caring therapist are worth betting on, certainly R cause for hope, and responsible for my unswerving faith in psychotherapy ll .A as a healing endeavor. n The overwhelming majority of psychotherapists, as corny as it sounds, tio ia want to be helpful. Many of us, including me, even answered in graduate oc school applications “I want to help people” as the reason we chose to be thera- ss pists (see Figure 1.1). Often, some well-meaning person dissuaded us from that lA answer because it didn’t sound sophisticated or appeared too “codependent.” ca Such aspirations, however, are not only noble but also can provide just what gi is needed to improve your effectiveness. After all, there is not much finan- lo ho cial incentive for doing better therapy—we don’t do this work because we yc thought we would acquire the lifestyles of the rich and famous. It is amazing Ps to think, in these hard economic times, that smart, creative individuals an make the necessary sacrifices to attain advanced degrees only to earn far less ic money than those with comparable degrees in other fields. It says something er Am ht 1Although I didn’t consider it while it was happening, the gender politics of this situation are noteworthy. rig Later, and over time, I talked with Tina about what taking off her clothes meant. Two ways of under- y standing her behavior emerged from our discussions. First, disrobing in the face of male authority andop pressure to perform usually ended the encounter—it allowed her to exert some control over a continualC demand for compliance. Second, it was a way that Tina learned to prevent brutal physical abuse by her father. In effect, Tina learned to trade sexual abuse for beatings. When I conveyed the meanings of Tina’s behavior as well as my palpable annoyance, it ended the staff’s use of Tina as “a rite of passage.” SO YOU WANT TO BE A BETTER THERAPIST 5 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  4. 4. I just want to help people! n. tio bu tri is rD fo ot N d. ve er es R s ht ig R ll n .A tio ia oc ss lA ca gi lo ho yc Ps an ic er Figure 1.1. Barry just wanted to help people. Am ht quite good about us and our career choice, although less kind interpretations rig are readily available. yop Doing the required servitude without the promise of a rags-to-richesC future only makes sense because being a psychotherapist is more of a calling than a job—a quest for meaningful activity and personal fulfillment (Orlinsky et al., 2005). Parks (1996, p. 12) summarizes: 6 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  5. 5. Accounts by psychotherapists of their professional [work] suggest that the feelings they experience while practicing therapy are very important in motivating their therapeutic work and that, generally, therapists enjoy working with patients and derive a deep sense of personal satisfaction from doing therapy (Dryden & Spurling, 1989; Guy, 1987). That these feelings are intrinsically satisfying, and not a reward on a par with money or profes- n. sional prestige, is evident from the terms that therapists use. Working with tio patients is described as “interesting” and “fascinating” (Bloomfield, 1989), bu “nourishing” (Thorne, 1989), “meaningful” and “stimulating” (Heppner, tri 1989), “exciting” (Fransella, 1989), and “sustaining” (Street, 1989). Some is consider it a “privilege” (Mahoney, 1989; Chaplin, 1989). It clearly repre- rD sents a part of life which has serious personal meaning and value and which fo therapists would be most reluctant to give up (Fransella, 1989). ot N Despite good intentions and commitment to your work, making sense of d. the cacophony of “latest” developments, let alone applying them in your prac- ve tice, may feel overwhelming. Every day, it seems, there are new fully manual- er ized treatments hot off the press, promising evidence-based change and es R increased effectiveness with this or that disorder. In your day-to-day work with s clients, however, it is never so black-and-white. It is often difficult to even ht ig know if you’re achieving the desired results—or worse, you might realize that R you’re not reaching a particular client but have no idea why and no clue what ll .A to do about it. Even if your overall success rates are good, the accumulation of n unfruitful encounters over time can weigh on you and erode the aspirations io that led you to become a therapist. You read as much as you can, you try new t ia oc approaches, but despite all the hard work you feel as though you’re missing ss something—some, if not many, clients still do not respond to your best efforts. lA How can you achieve better results? In short: how can you become a better ca therapist? gi This book intends to help you answer your calling and remember why lo ho you became a therapist in the first place. It is not about learning the latest and yc greatest miracle method, or a never-before-available way to unravel the mys- Ps teries of the human psyche, or the most recent breakthrough in brain neuro- an chemistry. No husky voiceover will declare a winner of the battle of the ic psychotherapy brands or add yet another fashion to the therapy boutique of er techniques. You have already been there and done that. It is also not about Am becoming “accountable” for the sake of funding sources or to justify your exis- ht tence via showing “proof of value” or “return on investment.” Rather, this rig book is about you—this time it’s personal, from one therapist to another. It’s yop about becoming a better therapist because you got into this business to helpC people—you want to make a meaningful difference in as many lives as possi- ble. Being a therapist is more than a way to make a living to you. Becoming a better one is what you are about. SO YOU WANT TO BE A BETTER THERAPIST 7 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  6. 6. THE GOOD, THE BAD, AND THE UGLY To exchange one orthodoxy for another is not necessarily an advance. The enemy is the gramophone mind, whether or not one agrees with the record that is being played at the moment. —George Orwell n. The good news is that the efficacy of psychotherapy is very good—the tio bu average treated person is better off than about 80% of the untreated sample tri (Duncan, Miller, Wampold, & Hubble, 2010), translating to an effect size (ES) is of about 0.8.2 Moreover, these substantial benefits apparently extend from rD the laboratory to everyday practice. For example, a real-world study in the fo UK (Stiles, Barkham, Twigg, Mellor-Clark, & Cooper, 2006) comparing ot cognitive–behavioral therapy (CBT), psychodynamic therapy (PDT), and N d. person-centered therapy (PCT) as routinely practiced reported a pre–post ve ES of around 1.30. In short, there is a lot to feel proud about our profession: er psychotherapy works. es But there’s more to the story. The bad news is twofold: First, dropouts are R a significant problem in the delivery of mental health and substance abuse ser- s ht vices, averaging at least 47% (Wierzbicki & Pekarik, 1993). When dropouts are ig considered, a hard rain falls on psychotherapy’s efficacy parade, both in random- R ll ized clinical trials (RCT) and in clinical settings. Second, despite the fact that .A the general efficacy is consistently good, not everyone benefits. Hansen, n io Lambert, and Foreman (2002), using a national database of over 6000 clients, t ia reported a sobering picture of routine clinical care in which only 20% of clients oc improved as compared to the 57–67% rates typical of RCTs. Whichever rate is ss accepted as more representative of actual practice, the fact remains that a sub- lA stantial portion of clients go home without help. ca And the ugly: Explaining part of the volatile results, variability among gi lo therapists is the rule rather than the exception. Not surprisingly, although rarely ho discussed, some therapists are much better at securing positive results than yc others. In fact, therapist effectiveness ranges from 20–70%! Moreover, even Ps very effective clinicians seem to be poor at identifying deteriorating clients. an Hannan et al. (2005) compared therapist predictions of client deterioration to ic actuarial methods. Though therapists were aware of the study’s purpose, famil- er Am iar with the outcome measure used, and informed that the base rate was likely to be 8%, they accurately predicted deterioration in only 1 out of 550 cases; ht yrigop 2Effect size (ES) refers to the magnitude of change attributable to treatment, compared to an untreatedC group. The ES most associated with psychotherapy is 0.8 standard deviations above the mean of the untreated group. An ES of 1.0 indicates that the mean of the treated group falls at approximately the 84th percentile of the untreated one. Consequently, the average treated person is better off than approximately 80% of those without the benefit of treatment. 8 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  7. 7. psychotherapists did not identify 39 out of the 40 clients who deteriorated. In contrast, the actuarial method correctly predicted 36 of the 40. So, despite the overall efficacy and effectiveness of psychotherapy, drop- outs are a substantial problem, many clients do not benefit, and therapists vary significantly in effectiveness and are poor judges of client deterioration. Most of us provide an invaluable service to our clients, but sadly most of us don’t n. know how effective we really are—we don’t know who will drop out or who will tio ultimately not benefit or even deteriorate. Do you know how effective you are? bu With dropouts considered, how many of your clients leave your office absent of tri is benefit? Which clients in your practice now are at risk for dropout or negative rD outcome? fo What is the solution to these problems? Sometimes our altruistic desire ot to be helpful hoodwinks us into believing that if we were just smart enough or N trained correctly, clients would not remain inured to our best efforts—if we d. ve found the Holy Grail, that special model or technique, we could once and for er all defeat the psychic dragons that terrorize clients. We come by this belief es honestly—we hear it all the time, constantly reinforced on nearly all fronts. R The warring factions carry on the struggle for alpha dogma status in the psy- s ht chotherapy pack and claims of “miracle cures better than the rest” continue ig unabated. In a recent article in the Psychotherapy Networker, the most read R publication by mental health professionals, several approaches were identified ll .A as significant advancements (Lebow, 2007, p. 46). The article swooned with n praise (e.g., “impressive outcomes, outcomes light–years ahead”)—the subtext tio ia is that if we don’t avail ourselves of these approaches we are doing our clients oc a reprehensible disservice—but left out a vital fact: None of the heralded mod- ss els have reliably demonstrated superiority to any other systematically applied lA psychotherapy. ca This, of course, is the famous dodo bird verdict (“All have won and all must gi have prizes”), taken from the classic Lewis Carroll (1865/1962) tale, Alice in lo ho Wonderland, first invoked by Saul Rosenzweig way back in 1936 to illustrate yc the equivalence of outcome among approaches (see Duncan, 2010). The Ps dodo verdict is the most replicated finding in the psychological literature— an encompassing a broad array of research designs, problems, populations, and ic clinical settings. For example, the study mentioned previously (Stiles et al., er 2006) comparing CBT, PDT, and PCT as routinely practiced, once again Am found no differences among the approaches. ht Perhaps a more controversial illustration is provided by the treatments rig for the diagnosis du jour, posttraumatic stress disorder (PTSD). CBT has been yop demonstrated to be effective and is widely believed to be the treatment ofC choice, but several approaches with diverse rationales and methods have also been shown to be effective: eye-movement desensitization and reprocessing, cognitive therapy without exposure, hypnotherapy, psychodynamic therapy, SO YOU WANT TO BE A BETTER THERAPIST 9 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  8. 8. and present-centered therapy. A recent meta-analysis comparing these treat- ments found all of them about equally effective (Benish, Imel, & Wampold, 2007). What is remarkable here is the diversity of methods that achieve about the same results. Two of the treatments, cognitive therapy without expo- sure and present-centered therapy, were designed to exclude any therapeutic actions that might involve exposure (clients were not allowed to discuss their n. traumas because that invoked imaginal exposure). Despite the presumed tio extraordinary benefits of exposure for PTSD, the two treatments without it, or bu in which it was incidental (psychodynamic), were just as effective (Benish tri is et al., 2007). This study only confirms that the competition among the more rD than 250 therapeutic schools remains little more than the competition among fo aspirin, Advil, and Tylenol. All of them relieve pain and work better than no ot treatment at all. As the dodo wisely judged, all deserve prizes because none N stands above the rest. When it is all said and done, model differences only d. ve amount to an ES of about 0.2, an underwhelming 1% of the overall variance er of outcome (Wampold, 2001). es Unfortunately, the mountain of evidence researchers have amassed has R had little impact on the graduate or postgraduate training of mental health s ht professionals, or sadly, on professional attitudes. We spend thousands of dol- ig lars on workshops, conferences, and books to learn highly publicized methods R of treatment. Unfortunately, instead of feeling hopeful or validated and expe- ll .A riencing the promised “outcomes light–years ahead,” we often wind up feeling n demoralized. Why didn’t the powerful sword slay the dragon of misery of the tio ia client in my office now? The answer all too often is to blame ourselves—we oc are just not measuring up. The Holy Grail seems just out of reach. ss Don’t get me wrong. There is nothing wrong with learning about mod- lA els and techniques—in fact, it is a good thing as I’ll discuss below and through- ca out the book—but becoming beholden to one isn’t, nor is believing that gi salvation will come from them. They are indeed false gods. First, given the lo ho robust findings supporting the dodo verdict, it is important to keep in mind yc that the much ballyhooed models have only shown themselves to be better Ps than sham treatments or no treatment at all, which is not exactly news to write an home to mom about. Think about it. What if one of your friends went out on ic a date with a new person, and when you asked about the guy, your friend er replied, “He was better than nothing—he was unequivocally better than Am watching TV or washing my hair.” (Or, if your friend was a researcher: “. . . he ht was significantly better, at a 95% confidence level, than watching TV or wash- rig ing my hair.”) How impressed would you be? yop And second, the idea that change primarily emanates from the model orC techniques you wield is a siren call destined to smash you against the jagged rocks of ineffective therapy. That therapists might possess the psychological equivalent of a “pill” for emotional distress resonates strongly with many, and 10 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  9. 9. is nothing if not seductive as it teases our desires to be helpful. A treatment for a specific “disorder,” from this perspective, is like a silver bullet, potent and transferable from research setting to clinical practice. Any therapist need only to load the silver bullet into any psychotherapy revolver and shoot the psychic werewolf stalking the client. In its most unfortunate interpretation, clients are reduced to a diagnosis and therapists are defined by a treatment technology— n. both interchangeable and insignificant to the procedure at hand. This prod- tio uct view of psychotherapy is most empirically vacuous because the treatment bu itself accounts for so little of outcome variance, while the client and the tri is therapist—and their relationship—account for so much more. rD Fear is also a potent motivator for the ongoing search for the Holy Grail. fo Going well beyond subtext, we are told that not administering the “right” ot treatment is unethical (Chambless & Crits-Christoph, 2006) and even “pros- N ecutable”! A New York Times article reported: d. ve Using vague, unstandardized methods to assist troubled clients ‘should er be prosecutable’ in some cases, said Dr. Marsha Linehan . . . (Carey, es 2005, p. 2) R s Given the relative contribution of model and technique to change and ht ig the lack of demonstrated superiority of dialectical behavior therapy or any other R approach, perhaps it should be “prosecutable” to make such bold statements. ll .A In truth, we are easily smitten by the lure of flashy techniques and “out- n comes light-years ahead.” Amid explanations and remedies aplenty, therapists tio courageously continue the search for designer explanations and brand name ia oc miracles—disconnected from the power for change that resides in the pairing ss of two unique persons, the application of strategies that resonate with both, and lA the impact of a quality partnership. Despite our generally good results and her- ca culean efforts to master the right approach, we continue to observe that clients gi drop out or, even worse, continue without benefit. lo ho yc To the Rescue: Practice-Based Evidence Ps an There is a practical clinical solution to these everyday pitfalls called ic “practice-based evidence” (Barkham et al., 2001; Duncan, Miller, & Sparks, er 2004). Howard, Moras, Brill, Matinovich, and Lutz (1996) were the first to Am advocate for the systematic evaluation of client response to treatment dur- ht ing the course of therapy, and to recommend that such information be used rig to “determine the appropriateness of the current treatment . . . the need for yop further treatment . . . [and] prompt a clinical consultation for patients whoC [were] not progressing at expected rates” (p. 1063). When this occurs—when client feedback is systematically collected and used to tailor treatment—good things happen. For example, using the Outcome Questionnaire 45.2, feedback SO YOU WANT TO BE A BETTER THERAPIST 11 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  10. 10. pioneer Michael Lambert has conducted five RCTs and all five demonstrated significant gains for feedback groups over treatment as usual (TAU) for clients at risk for a negative outcome. Twenty-two percent of TAU at-risk cases reached reliable improvement and clinically significant change, compared with 33% for feedback to therapist groups, 39% for feedback to therapists and clients, and 45% when feedback was supplemented with support tools such n. as measures of the alliance (Lambert, 2010). The addition of client feedback tio alone, without new techniques or models of treatment and leaving therapists bu to practice as they saw fit, enabled over two times the amount of at-risk clients tri is to benefit from psychotherapy. Think of that advantage in your practice. rD Consider the pool of clients in your practice right now who are not benefiting. fo Systematic feedback could allow you to recapture good outcomes with many ot of those clients who would otherwise not benefit. N Continuous client feedback individualizes psychotherapy based on treat- d. ve ment response, provides an early warning system that identifies at-risk clients er thereby preventing dropouts and negative outcomes, and suggests a tried and es true solution to the problem of therapist variability, namely, that feedback R necessarily improves performance and quickens the pace of your development. s ht In truth, practice-based evidence can make you a better therapist—it helps you ig get in the zone of effective psychotherapy.3 R ll n .A GETTING IN THE ZONE tio ia oc To follow knowledge like a sinking star, ss Beyond the upmost bound of human thought . . . lA To strive, to seek, to find, and not to yield. ca —Tennyson gi In a remarkable study, veteran researchers David Orlinsky and Helge lo ho Rønnestad (2005) took an in-depth look at therapists’ experience of their yc work and professional growth. Over a 15-year period, they collected richly Ps detailed reports from nearly 5,000 psychotherapists of all career levels, pro- an fessions, and theoretical orientations from over a dozen countries. From their ic analyses of many specific aspects of therapeutic work, two independent modes er of therapist participation were identified: Am Healing Involvement reflects a mode of participation in which therapists ht experience themselves as personally committed and affirming to patients, yrigop 3The rationale is compelling for securing client feedback. But before this understanding of how feedbackC could address psychotherapy’s pitfalls, before the randomized clinical trials demonstrating the power of feedback, and before the validation studies verified the psychometrics of the measures and that the process might be viable, there was a desire to give clients a voice in their own care, to bring them into the inner circle of decision making. 12 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  11. 11. engaging at a high level of basic empathic and communication skills, con- scious of Flow-type feelings during sessions, having a sense of efficacy in general, and dealing constructively with difficulties if problems in treat- ment arose. By contrast, Stressful Involvement is a pattern of therapist expe- rience characterized by frequent difficulties in practice, unconstructive efforts to deal with those difficulties by avoiding therapeutic engagement, n. and feelings of boredom and anxiety during sessions. (p. 162) tio An Effective Practice, according to the researchers, is characterized by much bu Healing Involvement and little Stressful Involvement. Healing Involvement tri is represents us at our best—the way we want to be with our clients. Think of it rD as being “in the zone,” akin to how athletes describe their experience when fo their performance is optimal. ot Elite athletes talk a lot about being in the zone, that magical place where N mind and body work in perfect synch, flowing without conscious effort to d. ve athletic nirvana. Perhaps the best theoretical explanation of the zone comes er from Mihaly Csikszentmihalyi in his book Flow: The Psychology of Optimal es Experience. Flow is a state of deep focus that occurs when people engage in R challenging tasks that demand intense concentration and commitment— s ht when skill level is perfectly balanced to the challenge level of a task that has ig clear goals and provides immediate feedback (Csikszentmihalyi, 1990). R All kinds of activity can trigger flow. People talk of “losing track of time” ll .A when they are gardening, playing softball, cooking an elaborate meal, or con- n ducting psychotherapy. We’ve all had the experience where we’ve become so tio ia completely absorbed in our work that time flies by, the outside world is a mil- oc lion miles away, and our talents flow freely—those times when our immersion ss into our client’s story is so complete, our attunement so sharp, and the path lA required for change eminently accessible. These episodes can be deeply grat- ca ifying, and some of our best work comes out of them. Sometimes you feel the gi texture of your connection with clients, an intimate space where you both lo ho know that there is something very good about this conversation, something yc that inspires hope. This is healing involvement. So, what causes this and, more Ps important, how can we make it happen more often? an Here is where the research of Orlinsky and Rønnestad is priceless. Their ic extensive investigation identified three sources of healing involvement, a ther- er apist’s experience of being in the zone: First is the therapist’s sense of cumula- Am tive career development—improvement in clinical skills, increasing mastery, and ht gradual surpassing of past limitations. Therapists like to think of themselves as rig getting better, over time, at what they do. Eighty-six percent of the therapists, yop regardless of career level, reported that they were “highly motivated” to pur-C sue professional development. This is truly remarkable. There is no other pro- fession, as a group, more committed to getting better at what they do. Most professions, it appears, believe that one arrives at some degree of competency SO YOU WANT TO BE A BETTER THERAPIST 13 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  12. 12. at some point. Not therapists. They want to continue to get better throughout their careers. Second, as implied, another important influence on healing involvement is the therapist’s sense of theoretical breadth. Orlinsky and Rønnestad suggest that understanding clients from a variety of conceptual contexts enhances the therapist’s adaptive flexibility in responding to the challenges of clinical work. n. Indeed, broad-spectrum integrative-eclectic practitioners were more likely to tio experience healing involvement. This suggests that therapists who are in the bu zone more do not marry any model, but rather remain theoretically promiscu- tri is ous. Again this makes sense. Possessing a range of understandings of client rD problems as well as possible methods to address them allows therapists to expe- fo rience healing involvement more often with more clients—a suggestion in ot line with what the psychotherapy integration movement has been telling us N all along (e.g., Norcross & Goldfried, 2005; Stricker & Gold, 2006). d. ve The third and by far the most powerful influence on being in the zone is er the therapist’s sense of currently experienced growth. Therapists like to think of es themselves as developing now. Your ongoing experience of professional devel- R opment is therefore critical to becoming a better therapist. In a sense we con- s ht tinually ask ourselves, “What have you done for me lately?” Therapists with ig the highest levels of current growth showed the highest levels of healing R involvement. Orlinsky and Rønnestad suggest that the experience of current ll .A growth translates to positive work morale and energizes therapists to apply n their skills on behalf of clients. In addition, currently experienced growth fos- tio ia ters a process of continual professional reflection (Rønnestad & Skovholt, oc 1991), a bonus that keeps therapists motivated to seek out specialty training, ss supervision, personal therapy, or what-have-you to keep the pedal down on lA the developmental process. It makes sense, when you think about it, that if we ca see our work as a calling and a means to personal meaning and satisfaction, gi then our view of our own growth as a therapist would be quite important to lo ho us—so much so that we might do well to keep a finger on the pulse of our yc development at all times. Ps How do therapists attain a sense of currently experienced growth? an According to Orlinsky and Rønnestad (2005), the most widely endorsed ic positive influence was practical–experiential learning through direct clini- er cal work—by the quality of therapists’ experiences in working with clients. Am Not workshops and books trumpeting the latest and greatest. Rather, almost ht 97% of therapists reported that learning from their experiences with rig clients was a significant influence on their development. A full 84% rated yop this influence as high. In truth, beyond cliché, therapists do believe thatC clients are the best teachers. Our sense of currently experienced growth depends on these frontline lessons, which in turn, is a primary source of healing involvement. 14 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  13. 13. How does all this relate to client feedback? Tracking client responses to therapy provides an accessible route to being in the zone, addressing all three sources identified by Orlinsky and Rønnestad. First, collection of client feed- back allows you to monitor your outcomes and plot your career development, so you will know about your effectiveness and whether you are improving. Moreover, charting your outcomes not only permits a more systematic process n. of planning and implementing strategies to improve your effectiveness, but it tio also permits your evaluation of the strategies and whether or not your time bu tri might be better spent elsewhere. Second, tailoring your approach based on is client feedback about benefit and the fit of the services will lead you to theo- rD retical breadth as you expand your repertoire to serve more clients. Soliciting fo client feedback enhances your ability to be tuned to client preferences and ot encourages your flexibility to try out new ideas in search of what resonates with N d. clients—opening you to a range of theoretical explanations and attending ve methods. Finally, securing client feedback seats you in the front of the class so er you can readily see and hear the lessons of the day—to experience your cur- es rently experienced growth. Later, I’ll show how client feedback or practice-based R evidence encourages your continual professional reflection with each client, s ht thereby increasing your learning potential exponentially. Client feedback is ig R the compass that provides direction out of the wilderness of negative out- ll comes and average therapy—taking the notion of clients as the best teachers .A of psychotherapy well beyond cliché, significantly accelerating your develop- n io ment as a therapist, and helping you become a better one. t ia oc ss lA CLIENTS ARE THE BEST TEACHERS ca gi Of all tyrannies, a tyranny sincerely exercised for the good of its victims lo may be the most oppressive. ho —C. S. Lewis yc Ps Dan Ariely, in his book Predictably Irrational (2008; see also http://www. an youtube.com/watch?v=8I6wa3eK6zQ), tells a horrendous story of an explo- ic sion that left him with 70% of his body covered with third-degree burns. er His treatment included a much-dreaded daily removal of his bandages. In Am the absence of skin, the bandages were attached to raw bleeding flesh and ht their removal was both harrowing and excruciatingly painful. The nurses rig removed the bandages as fast as possible, quickly ripping them off one by yop one. Believing that a slower pace would be less painful, Ariely repeatedlyC asked the nurses to slow down the removal process. The nurses, however, asserted that finishing as fast as possible was the best approach, and contin- ued to do so. SO YOU WANT TO BE A BETTER THERAPIST 15 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  14. 14. This ordeal miraculously inspired Ariely to research the experience of pain as well as other phenomena. His investigation of pain demonstrated that a slow and less intense experience of pain over longer periods was far easier to tolerate than more intense pain over shorter time frames. Consider this story and its relevance to psychotherapy. It is noteworthy that the nurses dis- regarded Ariely’s response to their removal methods—his experience of his n. own pain did not hold much weight! Ignoring his response as well as his plead- tio ings to slow down was not because the nurses were evil or had any malevolent bu intentions—in fact, Ariely reports that he grew to love the nurses and believed tri is that they loved him as well. Rather, the nurses assumed they knew more about rD his pain than he did and went full steam ahead for his own good! He also later fo learned that the nurses considered it easier for them to remove the dressings ot quickly. Clinical lore about the rapid removal of bandages, as well as what was N convenient for the nurses, prevailed over Ariely’s experience of his own pain. d. ve When services are provided without intimate connection to those er receiving them and to their responses and preferences, clients become card- es board cutouts, the object of our professional deliberations and subject to our R whims. Valuing clients as credible sources of their own experiences allows us s ht to critically examine our assumptions and practices—to support what is work- ig ing and challenge what is not—and allows clients to teach us how we can be R the most effective with them. ll .A The idea that clients are the best teachers has a long and rich history in n psychotherapy. Indeed, it is difficult if not impossible to routinely sit with tio ia people in the throes of emotional or situational disaster, then witness their oc journey to a better place, and not be changed by that experience. Some have ss written about the reversal of roles that can happen between therapists and lA clients, where therapists emerge as the main beneficiary of the therapeutic ca process; others have written about the profound lessons that clients teach us gi about life; still others have pointed to even a higher learning, an experience lo ho that was personally and professionally transformational. There are also yc compendiums of such lessons. Veteran psychotherapy researcher Marvin Ps Goldfried (2001), for example, compiled a series of clinical events that an resulted in conceptual revisions among well-known theorists. In a book about ic the changes incurred in experienced therapists lives (Kahn & Fromm, 2001), er Spiegel (2001) notes the personal changes he has made because of his work Am with cancer patients—their struggles regarding impending death inspired him ht to live his own life more intensely. In their compelling book, The Client Who rig Changed Me, prolific authors Jeffrey Kottler and Jon Carlson (2005) focused yop their efforts on the really big changes that therapists experience as a directC result of their work with clients. Clients provide the opportunity for constant learning about the nature of the human condition and about different cultures and worldviews, as well 16 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  15. 15. as the myriad ways by which people transcend adversity and cope with the unthinkable. With each session under our belt, we become more knowledge- able about people and worldly in our views. While these types of hard-learned lessons—the everyday and the transformational—are noteworthy (and this book contains client stories influential in my development as a therapist), the notion that “the client is the best teacher” is invoked here in a different way. n. It carries a far more literal meaning. Continuous client feedback permits a tio practical process in which clients proactively shape our behavior until we get bu it right with them or we move them on to someone else. tri is Acquiring formal feedback enables a transparent conversation unlike rD what most of us have ever experienced. With a collaborative focus on the ben- fo efit and fit of psychotherapy, clients can teach us how to do more effective work, ot specifically, on a session-by-session, and even within-session, basis. Beyond les- N sons about life or about the work of psychotherapy in general, a culture of con- d. ve tinuous client feedback keeps our utmost attention on the here and now with er this client in this session. Clients teach us with their responses—whether or not es they are benefiting and whether or not our service is a good fit for them—as well R as with their reactions and reflections about the next step. In short, practice- s ht based evidence enables your clients to teach you how to do better work, espe- ig cially those who are not responding to your therapeutic business as usual. R ll n .A io WHAT WORKS IN THERAPY: GUIDELINES FROM RESEARCH t ia oc Whoever acquires knowledge and does not practice it resembles him [sic] ss who ploughs his land and leaves it unsown. lA —Sa’di, Gulistan ca gi A story illustrates the sentiments that many practitioners feel about lo ho research. Two researchers were attending their annual conference. Although yc enjoying the proceedings, they decided to find some diversion to combat the Ps tedium of sitting all day and absorbing vast amounts of information. They set- an tled on a hot-air balloon ride and were quite enjoying themselves until a mys- ic terious fog rolled in. Hopelessly lost, they drifted for hours until, finally, a er clearing in the fog appeared and they saw a man standing in an open field. Am Joyfully, they yelled down at the man, “Where are we?” The man looked at ht them, and then down at the ground, before turning a full 360 degrees to sur- rig vey his surroundings. Finally, after scratching his beard and what seemed to yop be several moments of facial contortions reflecting deep concentration, theC man looked up and said, “You are above my farm.” The first researcher looked at the second researcher and said, “That man is a researcher—he is a scientist!” To which the second researcher replied, SO YOU WANT TO BE A BETTER THERAPIST 17 On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx
  16. 16. “Are you crazy, man? He is a simple farmer!” “No,” answered the first researcher emphatically, “that man is a researcher and there are three facts that support my assertion: First what he said was absolutely 100% accurate; second, he systematically addressed our question through an examination of all of the empirical evidence at his disposal, and then carefully deliberated before deliv- ering his conclusion; and finally, the third reason I know he is a researcher is n. that what he told us is absolutely useless to our predicament.” In this book, I tio only present research that directly informs my psychotherapy practice and that bu will be useful to your predicament. If it doesn’t pass that test, you will not read tri is it here. rD The common factors—what works in therapy—have a storied history fo that started with Rosenzweig’s (1936) classic article “Implicit Common ot Factors in Diverse Forms of Psychotherapy.” In addition to the original invo- N cation of the dodo bird and seminal explication of the common factors of d. ve change, Rosenzweig also provided the best explanation for the common fac- er tors, still used today, namely, that given that all approaches achieve roughly es similar results, there must be pantheoretical factors accounting for the R observed changes beyond the presumed differences among schools (Duncan, s 2010). ht ig Jerome Frank (Frank, 1961, 1973; Frank & Frank, 1991) advanced the R idea that psychotherapy orientations (and other forms of healing) are equiva- ll .A lent in their effectiveness because of factors shared by all: (a) a healing setting; n (b) a rationale, myth, or conceptual framework that provides an explanation tio ia for the client’s complaint and a method for resolving it; (c) an emotionally oc charged, confiding relationship with a helping person; and (d) a ritual or pro- ss cedure that requires involvement of both the healer and client to bring about lA “cure” or resolution. Frank’s work is particularly helpful, as noted below, in ca understanding the role of model and technique as the vehicle for delivering gi the other factors. lo ho Several others have identified these elements found in all therapies, but yc Brigham Young University’s Michael Lambert deserves special mention. After Ps an extensive analysis of decades of outcome research, Lambert (1986) identi- an fied four factors—and their estimated percentages of outcome variance—as ic the principal elements accounting for improvement: extratherapeutic (client) er variables (40%); relationship factors (30%); hope, expectancy, and placebo Am (15%); and model/technique (15%) (see Figure 1.2). Although these factors ht are not derived from a statistical analysis, he suggested that they embody what rig studies indicated about treatment outcome. Lambert’s portrayal of the com- yop mon factors bravely differentiated factors according to their relative contribu-C tion to outcome, opening a new vista of understanding models and their proportional importance to success—a bold challenge to the typical reverence many researchers and therapists feel toward their preferred models. 18 ON BECOMING A BETTER THERAPIST On Becoming a Better Therapist, by B. L. Duncan Copyright 2011 by the American Psychological Association. All Rights Reserved. Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx

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