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From the Webinar of the same name: Presentation covering Chapter One of "On Becoming a Better Therapist" by Barry Duncan

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  1. 1. 7/22/2010 On Becoming a Better Therapist So You Want to Be A Better Therapist Barry Duncan, Psy.D. 954.721.2981 1
  2. 2. 7/22/2010 Winter Getaways! Advanced Trainings  CDOI Clinical Work: Becoming a Better Therapist—January 19-21, 2011 (18 hours of CEs) This 3 day intensive course is designed to take you to the next level of CDOI practice, as well as helping you become proactive about your development as a therapist. It goes way beyond the basics and includes live demonstrations with clients. HSCP Training of Trainers (TOT): January 24-28, 2011 (24 hours of CEs) This intensive training experience intends to give you all you need to begin training others in CDOI and/or implementing CDOI in your agencies. And it provides the first step in becoming an HSCP Certified Trainer of CDOI. 2
  3. 3. 7/22/2010 Starts With Our Clients My First Client, My First Story  In my first placement at the state hospital.  Tina was like many: young, poor, disenfranchised, heavily medicated, & on the merry-go-round of hospitalizations and at the ripe old age of 22, she was a “chronic schizophrenic.” Learning from Our Clients Thanks Tina  So Tina started my psychotherapy journey and offered up my first lessons: authenticity matters and when in doubt or in need of help, ask the client. Where ever you are Tina, thanks for that great start.  And we sure need their help to improve… 3
  4. 4. 7/22/2010 Psychotherapy The Good… Study after study, and studies of studies show the average treated client is better off than 80% of the untreated sample. Psychotherapy The Bad… Drop out rates average 47% Therapists vary… a lot 4
  5. 5. 7/22/2010 Therapist Differences Incredible Variation Among Providers TDCRP: top third psychiatrists giving placebo bested bottom third giving meds; clients of best therapists improve 50% more & dropped out 50% less; meds useful for clients of more effective therapists, not for less. Wampold, B., & Brown, J. (2006). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923. And the Ugly Providers Don’t Know  20-70% range  Therapists graded their effectiveness, A+ to F— 67% said A or better; none rated below average. Hansen, N., Lambert, M., Forman, E. (2002). The  Therapists don’t know psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9, 329-343. how effective they are Sapyta, J., Riemer, M., & Bickman, L. Feedback to  Surprising given… clinicians: Theory, research, and practice. Journal of Clinical Psychology: In Session, 61, 145-153 5
  6. 6. 7/22/2010 We Just Want to Help People Golly! I just want to help people • 17,000 clinical hours ago, I was a starry eyed new therapist….and • As a trainer, I have rubbed elbows with thousands of therapists & the thing that strikes me most is their authentic desire to be helpful. Becoming Better I Want To Help People • The majority of us want to be helpful. And always have—many answered “I want to help people” on school apps. Dissuaded from that answer…not sophisticated and appeared too “co- dependent.” 6
  7. 7. 7/22/2010 Becoming Better After All There is not much financial incentive—we don’t do this work because we thought we would acquire the lifestyles of the rich and famous. Becoming Better at What We Do More of a Calling • That smart, creative indvs make the sacrifices for advanced degrees only to earn far less than others says something • Required servitude w/o the promise of rags to riches only makes sense b/c it is more of a calling than a job—a quest for meaning & fulfillment 7
  8. 8. 7/22/2010 But How Do We Get Better? How Do We Get Better Pop Quiz Question #1: False Finding the right Study after study, and approach or studies of studies selecting evidence show that all based treatments treatments are the will improve right treatment—for treatment— outcomes some clients. 8
  9. 9. 7/22/2010 The Dodo Verdict •With few exceptions, partisan studies designed to prove the unique effects of a given model have found no differences— differences—nor has recent meta- meta- analyses…The analyses…The Dodo Verdict—the Verdict— most replicated finding in the psychological literature “Everybody has won and all must have prizes.” Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15. Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215. The Search for the Holy Grail Doesn’t Do Much for Us  Helping is no more effective now with all our treatment technologies (400 of them) and empirically supported treatments (almost 150 of them) than 40 years ago.  So how can we become better? 9
  10. 10. 7/22/2010 How Do We Get Better Pop Quiz Question #2: False Personal therapy and While therapists find increasing our self personal therapy awareness makes us a invaluable, it neither better person and helps nor hinders improves our outcomes outcomes. Geller, J., Norcorss, J.,& Orlinksky D. (2005). The Norcorss, psychotherapist’s Own Psychotherapy. New York: Oxford Univ. Press. Personal Therapy/Self Awareness The Royal Road to Better Outcomes? Idea arose from psychodynamic thinking…experience in client’s place makes sense, but, and this is a very big but, it doesn’t improve outcomes one iota! 10
  11. 11. 7/22/2010 How Do We Get Better Pop Quiz Question #3: FALSE Professional No difference in Training and outcomes between Continuing disciplines, training Education have a models, and not one direct impact on study supports CE as outcomes. outcomes. helping outcomes The Value of Training Another Nail in the Coffin  Need seems obvious, but it has long been known that professional training/discipline matters little to outcome  2010 issue of the JCD, Nyman, Nafziger, & Smith reported that it didn’t matter to outcome if the client was “seen by a licensed doctoral–level counselor, a pre-doctoral intern, or a practicum student.” 11
  12. 12. 7/22/2010 How Do We Get Better Pop Quiz Question #4: FALSE The accrued The cold hard reality wisdom of clinical is that experience experience, years of makes no difference. seasoning, improves outcomes Experience Is the Best Teacher? Getting Better All the Time?  All of us want to think that we are getting better.  But are we getting better or are we having the same year of experience over and over?  Less exp. therapists achieve about the same results so how do we get better? Contrary… 12
  13. 13. 7/22/2010 How Therapists Develop Orlinsky & Rønnestad • 5000 therapists • The Pinnacle of Development—Healing Involvement: committed & affirming, high level of empathic skills, conscious of “flow,” feeling effective, Orlinsky, D. E., Rønnestad, M. H. (2005). How psychotherapists develop: Washington, DC: APA. & dealing constructively w/ difficulties. How do we get there? First Source of Acceleration Cumulative Career Development • Improvement in skills, increasing mastery, & surpassing past limitations. • 86% “highly motivated” to pursue prof. dev. • No profession more committed—Therapists want to continue to get better over their careers 13
  14. 14. 7/22/2010 Sources of Acceleration Theoretical Breadth Therapists at every stage who combined several theoretical perspectives were the “most growing” & more likely to exp. Healing Involvement. Biggest Source of Development Currently Experienced Growth • “What have you done for me lately?” • Our work is a calling, so our dev. is important to us—so much so that we keep a finger on the pulse of it at all times. 14
  15. 15. 7/22/2010 How Do We Attain Currently Experienced Growth • Experiential learning thru clinical work • Beyond cliché, therapists believe that clients are the best teachers—our primary access to Growth More Self Delusion? • The astute participant might be thinking: “Wait a minute, isn’t Healing Involvement just more therapist self-delusions about how effective they are?” Yes, it would be if it weren’t for the client, and their feedback. 15
  16. 16. 7/22/2010 To The Rescue Consumer Driven Outcomes Management  Howard et al. (1996) advocated for the systematic eval. of client response during treatment to “determine the appropriateness of the current tx…the need for further tx…[and] prompt a clinical consultation for patients who [were] not progressing at expected rates” Feedback and Outcome Lambert’s Five Trials  All 5 sig. gains for feedback  22% of TAU at-risk cases improved compared with 33% for feedback to therapists, 39% for feedback to therapists & clients, & 45% when supplemented with support tools  A strong case for routine measurement of outcome in everyday clinical practice 16
  17. 17. 7/22/2010 Becoming Better Isn’t It Good, Norwegian Wood  Feedback v TAU; Both persons reliable or sig. change— 50.5% v. 22.6%; ES: .50; 4 xs # of clin. sig. change  FU: TAU-34.2% v. 18.4% Feedback Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a sep./divorce rate naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693-704. Barry Finds the Spot in the Norway Picture By Coincidence 17
  18. 18. 7/22/2010 Reese, Norsworthy, & Rowlands (2009) First Independent Study Reese, R., Norsworthy, L., &  N=148: Feedback group Rowlands, S. (2009). Does a continuous feedback model doubled controls (10.4 vs. 5.1 pts); ES: .48 improve psychotherapy outcomes? Psychotherapy,46, 418-431. Reese, R., Toland, M., Slone, N.,  Like Norway study, clients, regardless of risk & Norsworthy, L. (in press). Effect of client feedback on status, benefit from couple psychotherapy outcomes. Psychotherapy. continuous feedback  And the replication study now in press Therapist Development and Feedback • Client feedback monitors outcome & plots cumulative career development. • Tailoring services leads to theoretical breadth to serve more clients. • Securing client feedback places therapists in accelerated courses of development in the front of the class to see and hear the lessons of the day—to experience currently experienced growth. 18
  19. 19. 7/22/2010 Therapist Development Focusing on What Works: TDCRP •Considered most sophisticated comparative clinical trial ever: •CBT, IPT, Drug, Placebo •No difference in outcome •The client’s rating of the alliance at the second session the best predictor of outcome across conditions. Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82. Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) 30-?% 19
  20. 20. 7/22/2010 On Becoming A Better Therapist Bottom Line “The quality of the patient's participation . . .  Privilege clients’ [emerges] as experience & rally the most their resources to important the cause. determinant of outcome." Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of process -outcome research: In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 307-390). New York: Wiley. Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) Duncan, B. (2010). On becoming a better therapist. 30-?% Washington DC: American Psychological Association 20
  21. 21. 7/22/2010 Therapist Differences Incredible Variation Among Providers In the TDCRP, 8% of the overall variance in the outcomes within each treatment was due to therapists…or 62% of the variance attributed to treatment What accounts for the variability? Tune in later! Kim, D. M., Wampold, B. E., & Bolt, D. M. (2006). Therapist effects in psychotherapy: A random effects modeling of the NIMH TDCRP data. Psychotherapy Research, 16, 161-172. Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) Duncan, B. (2010). On becoming a better therapist. 30-?% Washington DC: American Psychological Association 21
  22. 22. 7/22/2010 The Alliance Bottom Line  The Alliance Matters—Big Time  TDCRP: alliance accounted for up to 21% of the overall variance… But What About This Client?  While the data give general guidance, it does little to inform what will help a particular client.  To know what is therapeutic, the client’s view regarding both the alliance and outcome is key.  The real question: Does this client experience this interaction at this time and place to be therapeutic? And the only way to do this is via client feedback 22
  23. 23. 7/22/2010 Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) Duncan, B. (2010). On becoming a better therapist. 30-?% Washington DC: American Psychological Association Feedback As A Common Factor  Overlaps with & affects all factors—tie that binds  Soliciting feedback is a living, process that engages clients in monitoring outcome, heightens hope, fits client preferences, maximizes therapist-client fit, and is itself a core feature of change. 23
  24. 24. 7/22/2010 Becoming Better Feedback Is My Compass • Not an uninhabited terrain of technical procedures, nor the predictable path of diagnosis, prescription, & cure. Cannot be described w/o the client & therapist, co-adventurers in a journey across uncharted territory. Common factors provide landmarks for this interpersonal & idiosyncratic trip, & specific models provide well- traveled directions to consider, but feedback provides the compass, showing the way to the desired destination. Becoming a Better Therapist Accelerate Your Development • Pre-requisite: you are a primary figure—the client is central, but it takes two to tango. Your growth impacts your ability to be vitally involved. 24
  25. 25. 7/22/2010 For the Love of the Work On Becoming a Better Therapist • If you got into this business, like me & the majority, because you wanted to help people, you already have what it takes. Two things: One is your commitment to monitor the alliance and the outcome of the services. The second is your investment in yourself, your own growth and development. Client feedback provides the method for both, the compass for the journey. About the Book and the Webinars The American Psychological Association is the publisher 2. Just the Facts, Ma’am’ 3..How Being Bad… 4.Getting in the Zone 5. Heart and Soul of Change 6.Wizards, Humbugs, Witches 7. For the Love of the Work 25