Greatest hits


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In this presentation, Barry Duncan surveys the last 25 years of psychotherapy research and identifies its greatest hits and disasters.


  • 1.www.heartandsoulofchange.com6/10/2010 Psychotherapy Researchs Greatest HitsThe Most Important Findings of the Last 30 YearsBarry Duncan, Psy.D. www.heartandsoulofchange.comPsy.D.954.721.2981www.whatsrighwithyou.combarrylduncan@comcast.net1

2. 6/10/2010 2 3. 6/10/2010 Psychotherapy ResearchsGreatest Hits The Four Greatest HitsThe Two Greatest Disasters Psychotherapy ResearchsGreatest Hits Number 4 The Dodo Bird Verdict 3 4. 6/10/2010 The Dodo Verdict With few exceptions, partisan studiesdesigned to prove the unique effectsof a given model have found nodifferencesdifferencesnor has recent meta-meta-analysesTheanalysesThe Dodo VerdicttheVerdictmost replicated finding in thepsychological literatureEverybody 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 Treatment of DepressionCollaborative Research Project (TDCRP)Considered to be the most sophisticated comparativeclinical trial ever conducted:Four approaches (CBT, IPT, Drug, Placebo).No difference in outcome between approachesThe clients rating of the alliance at the second sessionthe best predictor of outcome across conditions.Tx model accounted for (0-2% of the variance (0- Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82. 4 5. www.heartandsoulofchange.com6/10/2010 Project MATCH and the AllianceThe largest study ever conducted on the treatment of problem drinking:Three different treatment approaches studied (CBT, 12-step,12-and Motivational Interviewing). NO difference in outcome between approaches.The clients rating of the therapeutic alliance the bestpredictor of:Treatment participation;Drinking behavior during treatment;Drinking at 12-month follow-up. 12- follow- Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29.58, 7- 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 andand outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98. 65(4), 588- The Dodo Also Rules Family TherapyCannabis Youth Treatment Project 600 Adolescents marijuana users:Significant co-morbidity (3-12 problems). co-(3-Two arms (dose, type) and one of three types of treatment in each arm:Dose arm: MET+CBT (5 wks),MET+CBT (12 wks), Family SupportNetwork (12 wks)+MET+CBT;Type arm: MET/CBT (5 wks), ACRT (12weeks), MDFT (12 wks).Approach accounted for 0% of the variance in outcome. Ratings of the alliance predicted: Premature drop-out; Substance abuse and dependency drop- symptoms post-treatment, and cannabis use at 3 and 6 month 6. www.heartandsoulofchange.com6/10/2010Tired of RCTsThe Dodoin the Real World1999 study of 2000 providers and over 20,000 clients; 13 different orientations including CBT, SFBT, family therapy, medication, and eclectic 2006 study of 1309 clients compared six groups: CBT, PCT or PDT only, and one of these plus one additional approach (integrative, supportive, art) NO DIFFERENCE! In the UK study, all groups made marked improvement (ES = 1.36). Approach and purity accounted for tiny proportions of variance (1% & 0.5%. Stiles, W. B., Barkham, M., Twigg, E., Mellor-Clark, J., & Cooper, M. (2006). Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapiesas practised in UK National Health Service settings Psychological medicine 36, 555-566. Brown, J., Dreis, S., & Nace, D.K. (1999). What really makes a difference in psychotherapy outcome? Why does managed care wa nt to know? InM.A. Hubble, B.L. Duncan, and S.D. Miller (Eds.). The heart and soul of change: What works in therapy.. Washington, D.C.: APA Press, pp. 389-406. Implications of the Dodo Bird VerdictAll approaches work because of factors common to all: Of the clients abilities Client resources transcendmodel differences Time better spent recruitingwhat clients already have thanassessing what they need6 7. www.heartandsoulofchange.com6/10/2010 Factors Accounting forSuccessful Outcome 40.0%Spontaneous RemissionClient/Extratherapeutic Common Factors RelationshipModels/Techniques30.0%15.0%Placebo/Hope/Expectancy 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. Client/Extratherapeutic Factors (87%) Feedback Effects15-31%Alliance EffectsTreatment Effects38-54%13% Model/Technique8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69%Rationale/Ritual (General Effects)30-?%7 8. 6/10/2010 The Killer Ds of Client Diminishment Dysfunction Disorder Disability Disease Deficit Damaged Not Reliable or Valid None ever related tooutcomeClients Are the Lions of Change Until lions have their historians, tales of hunting will always glorify the hunter.African Proverb 8 9. www.heartandsoulofchange.com6/10/2010 Psychotherapy ResearchsGreatest Hits Number 3The Power of theAlliance Relationship Factors The Alliance: Relational Bond Agreement on goals38-38-54% Agreement on tasksSeven Times the Impact of Model/TechniqueAccounts for Most of Therapist VarianceDuncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass9 10. 6/10/2010 The Alliance: Over 1000 Research Findings Quality of the alliance morepotent predictor of outcome thanorientation, experience, orprofessional discipline-- recallTDCRP, MATCH, CYT. Clients rarely report negativereactions before deciding toterminate. Same holds true for youth andfamily therapy Research into PracticeThe AllianceIncreasingly, the relationship isviewed as merely setting the stagefor the real treatment:Confronting distorted thoughts;Recovering forgotten memories;Asking special questions;Tapping on or waving fingers in front of thefacebut the data say:The alliance deserves farmore RESPECT Duncan, B. (2010). On becoming a better therapist. Washington, DC: APA.10 11. www.heartandsoulofchange.com6/10/2010 Psychotherapy Researchs Greatest Hits: The AllianceClients Theory of ChangeMolly:Goals, A Client Example Meaning orMeans orMethods Purpose Clients View of the Therapeutic Relationship Psychotherapy ResearchsGreatest HitsNumber 2The Predictive Powerof Early Change 11 12. www.heartandsoulofchange.com6/10/2010 Psychotherapy Researchs Greatest Hits : Project Match Babor, T.F., & DelBoca, F.K. (eds.) (2003). Treatment Matching in Alcoholism. United Kingdom: Cambridge, 113. Alcoholism. Psychotherapy Researchs Greatest Hits: Early Change Cannabis Youth Treatment ProjectApproachDose 12 13. www.heartandsoulofchange.com6/10/2010 Early Change Predicts In a study of more than 2000 therapists,Brown found that if no improvementoccurred by the sixth visit, then noimprovement was likely over the entirecourse of treatment. Clients who worsened by the third visitwere twice as likely to drop out thanthose reporting progress. Variables such as diagnosis, severity, andtype of therapy were, not . . . asimportant [in predicting eventualoutcome] as knowing whether or not thetreatment being provided [was] actuallyworking.Implications Feedback about outcome is essential for clinical decision making. Do not need to know what tx to use for a given diagnosis as much as whether the current relationship is a good fit and providing benefit, and, if not, to adjust early to maximize the chances of success. 13 14. 6/10/2010Psychotherapy Researchs Greatest HitsNumber 1Client Feedback Dramatically ImprovesEffectivenessand Efficiency(more than anything else) Psychotherapy ResearchsGreatest Hits: Client Feedback One study of 6224 clients, Miller, Duncan et al (2006) provided therapists with real-time feedback regarding the clients experience of the alliance and progress. This practice-based evidence not only resulted in higher retention rates but also doubled the overall effect size of services offered (baseline ES = .37 v. final phase ES = .79; p < .001). Download these measures for free14 15. 6/10/2010 The Revolutionary Benefits As incredible as the results appear, they are entirely consistent with other findings. Lambert et al. (2003) reported that those relationships at risk which received formal feedback were better off than 65% of those without feedback (Average ES = .39!). Whipple et al. (2003) found that clients whose therapists had access to outcome and alliance info were less likely to deteriorate, and twice as likely to achieve change. Obtained without any attempt to control treatment process. Effects on Efficiency Cancellations, No Shows, LOSClaude (2004) compared the ave. # of sessions, canc., no shows, and % of long- term cases before and after OM. Sample: 2130 closed cases seen in a public CMHC. Ave. # of sessions dropped 40% (10 to 6) while outcomes improved by 7%; canc. and no show rates were reduced by 40% and 25%; and % of long term null cases diminished by 80% (10% to 2%). An estimated savings of $489,600. Such cost savings did not come at the expense of client satisfaction with servicesduring the same period satisfaction rates improved significantly.15 16. 6/10/2010 Psychotherapy Researchs Greatest Disasters Number 2DiagnosisDiagnosisI have found littlethat is good abouthuman beings. In myexperience, mo