OnBecomingCh1DiscussionSlides

www.heartandsoulofchange.com 7/22/2010

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Barry Duncan, Psy.D. www.heartandsoulofchange.comBarry Duncan, Psy.D. www.heartandsoulofchange.com954.721.2981 www.whatsrighwithyou.com954.721.2981 www.whatsrighwithyou.com

[email protected]@comcast.net

On Becominga Better Therapist

Chapter OneDiscussion


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Winter Getaways!Advanced TrainingsWinter Getaways!

Advanced Trainings CDOI Clinical Work: Becoming a Better

Therapist—January 19-21, 2011 (18hours of CEs)This 3 day intensive course is designed totake you to the next level of CDOI practice,as well as helping you become proactiveabout your development as a therapist. Itgoes way beyond the basics and includes livedemonstrations with clients.HSCP Training of Trainers (TOT):January 24-28, 2011 (24 hours of CEs)This intensive training experience intends togive you all you need to begin training othersin CDOI and/or implementing CDOI in youragencies. And it provides the first step inbecoming an HSCP Certified Trainer of CDOI.

CDOI Clinical Work: Becoming a BetterTherapist—January 19-21, 2011 (18hours of CEs)This 3 day intensive course is designed totake you to the next level of CDOI practice,as well as helping you become proactiveabout your development as a therapist. Itgoes way beyond the basics and includes livedemonstrations with clients.HSCP Training of Trainers (TOT):January 24-28, 2011 (24 hours of CEs)This intensive training experience intends togive you all you need to begin training othersin CDOI and/or implementing CDOI in youragencies. And it provides the first step inbecoming an HSCP Certified Trainer of CDOI.

Starts With Our ClientsMy First Client, My First Story

Starts With Our ClientsMy First Client, My First Story

In my first placement atthe state hospital.

Tina was like many:young, poor,disenfranchised, heavilymedicated, & on themerry-go-round ofhospitalizations and atthe ripe old age of 22,she was a “chronicschizophrenic.”

In my first placement atthe state hospital.

Tina was like many:young, poor,disenfranchised, heavilymedicated, & on themerry-go-round ofhospitalizations and atthe ripe old age of 22,she was a “chronicschizophrenic.”


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Learning from Our ClientsThanks Tina

Learning from Our ClientsThanks Tina

So Tina started mypsychotherapy journey andoffered up my first lessons:authenticity matters andwhen in doubt or in need ofhelp, ask the client. Whereever you are Tina, thanksfor that great start.

And we sure need their helpto improve…

So Tina started mypsychotherapy journey andoffered up my first lessons:authenticity matters andwhen in doubt or in need ofhelp, ask the client. Whereever you are Tina, thanksfor that great start.

And we sure need their helpto improve…

PsychotherapyThe Good, the Bad…

PsychotherapyThe Good, the Bad…

TreatmentTreatmentWorks, butWorks, but DropOuts Are aProblem,Therapists Varyin Effectiveness,and


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And the UglyProviders Don’t Know

And the UglyProviders Don’t Know

20-70% range

Therapists graded theireffectiveness, A+ to F—67% said A or better;none rated belowaverage.

Therapists don’t knowTherapists don’t knowhow effective they arehow effective they are

Surprising given…

20-70% range

Therapists graded theireffectiveness, A+ to F—67% said A or better;none rated belowaverage.

Therapists don’t knowTherapists don’t knowhow effective they arehow effective they are

Surprising given…

Hansen, 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, 145-153

We Just Want to Help People

• 17,000 clinical hours ago, Iwas a starry eyed newtherapist….and

• As a trainer, I have rubbedelbows with thousands oftherapists & the thing thatstrikes me most is theirauthentic desire to behelpful.

Golly! I just wantto help people


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Becoming Better at What We DoMore of a Calling

• That smart, creative indvsmake the sacrifices foradvanced degrees only toearn far less than otherssays something

• Required servitude w/othe promise of rags toriches only makes senseb/c it is more of a callingthan a job—a quest formeaning & fulfillment

But How Do We Get Better?But How Do We Get Better?


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Question #1:Question #1:

Finding the rightFinding the rightapproach orapproach orselecting evidenceselecting evidencebased treatmentsbased treatmentswill improvewill improveoutcomesoutcomes

FalseFalseStudy after study, andStudy after study, andstudies of studiesstudies of studiesshow that allshow that alltreatments are thetreatments are theright treatmentright treatment——forforsome clients.some clients.

How Do We Get BetterPop Quiz


The Search for the Holy GrailDoesn’t Do Much for Us

The Search for the Holy GrailDoesn’t Do Much for Us

Helping is no moreeffective now with all ourtreatment technologies(400 of them) andempirically supportedtreatments (almost 150 ofthem) than 40 years ago.

So how can we becomebetter?

Helping is no moreeffective now with all ourtreatment technologies(400 of them) andempirically supportedtreatments (almost 150 ofthem) than 40 years ago.

So how can we becomebetter?


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Personal therapy andPersonal therapy andincreasing our selfincreasing our selfawareness makes us aawareness makes us abetter person andbetter person andimproves our outcomesimproves our outcomes

FalseFalseWhile therapists findWhile therapists findpersonal therapypersonal therapyinvaluable, it neitherinvaluable, it neitherhelps nor hindershelps nor hindersoutcomes.outcomes.

Geller, J.,Geller, J., NorcorssNorcorss, J.,&, J.,& OrlinkskyOrlinksky D. (2005).D. (2005). TheThepsychotherapist’s Own Psychotherapy.psychotherapist’s Own Psychotherapy. New York:New York:Oxford Univ. Press.Oxford Univ. Press.




ProfessionalProfessionalTraining andTraining andContinuingContinuingEducation have aEducation have adirect impact ondirect impact onoutcomesoutcomes..

FALSEFALSENo difference inNo difference inoutcomes betweenoutcomes betweendisciplines, trainingdisciplines, trainingmodels, and not onemodels, and not onestudy supports CE asstudy supports CE ashelping outcomeshelping outcomes


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The accruedThe accruedwisdom of clinicalwisdom of clinicalexperience, years ofexperience, years ofseasoning,seasoning,improves outcomesimproves outcomes

FALSEFALSEThe cold hard realityThe cold hard realityis that experienceis that experiencemakes no differencemakes no difference..But contrary to myBut contrary to mycynical review…cynical review…

How Therapists DevelopOrlinsky & Rønnestad

• 5000 therapists

• The Pinnacle ofDevelopment—HealingInvolvement: committed& affirming, high level ofempathic skills, consciousof “flow,” feeling effective,& dealing constructivelyw/ difficulties. How do weget there?

Orlinsky, D. E., Rønnestad, M. H. (2005).How psychotherapists develop:Washington, DC: APA.


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How Therapists DevelopOrlinsky & Rønnestad

Three Sources ofTherapist Growth:

• Cumulative CareerDevelopment; TheoreticalBreadth, and the mostimportant, CurrentlyExperienced Growth

Orlinsky, D. E., Rønnestad, M. H. (2005).How psychotherapists develop:Washington, DC: APA.

More Self Delusion?

• The astute participantmight be thinking: “Wait aminute, isn’t HealingInvolvement just moretherapist self-delusionsabout how effective theyare?” Yes, it would be if itweren’t for the client, andtheir feedback.


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To The RescueConsumer Driven Outcomes Management

To The RescueConsumer Driven Outcomes Management

Howard et al. (1996) advocatedfor 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”

Howard et al. (1996) advocatedfor 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”

Feedback and OutcomeLambert’s Five Trials

Feedback and OutcomeLambert’s Five Trials

All 5 sig. gains for feedback

22% of TAU at-risk casesimproved compared with 33%for feedback to therapists,39% for feedback totherapists & clients, & 45%when supplemented withsupport tools

A strong case for routinemeasurement of outcome ineveryday clinical practice

All 5 sig. gains for feedback

22% of TAU at-risk casesimproved compared with 33%for feedback to therapists,39% for feedback totherapists & clients, & 45%when supplemented withsupport tools

A strong case for routinemeasurement of outcome ineveryday clinical practice


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Feedback v TAU;Both persons reliableor sig. change—50.5% v. 22.6%;ES: .50; 4 xs # ofclin. sig. change

FU: TAU-34.2% v.18.4% Feedbacksep./divorce rate

Feedback v TAU;Both persons reliableor sig. change—50.5% v. 22.6%;ES: .50; 4 xs # ofclin. sig. change

FU: TAU-34.2% v.18.4% Feedbacksep./divorce rate

Anker, 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.

Becoming BetterIsn’t It Good, Norwegian Wood

Becoming BetterIsn’t It Good, Norwegian Wood

Barry Finds the Spot in the Norway Picture

By Coincidence


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Reese, Norsworthy, & Rowlands (2009)First Independent Study

Reese, Norsworthy, & Rowlands (2009)First Independent Study

N=148: Feedback groupdoubled controls (10.4vs. 5.1 pts); ES: .48

Like Norway study,clients, regardless of riskstatus, benefit fromcontinuous feedback

And the replication study

now in press

N=148: Feedback groupdoubled controls (10.4vs. 5.1 pts); ES: .48

Like Norway study,clients, regardless of riskstatus, benefit fromcontinuous feedback

And the replication study

now in press

Reese, R., Norsworthy, L., &Rowlands, S. (2009). Does acontinuous feedback modelimprove psychotherapyoutcomes? Psychotherapy,46,418-431.

Reese, R., Toland, M., Slone, N.,& Norsworthy, L. (in press).Effect of client feedback oncouple psychotherapyoutcomes. Psychotherapy.

Therapist Developmentand Feedback

• Client feedback monitorsoutcome & plots cumulativecareer development.

• Tailoring services leads totheoretical breadth to servemore clients.

• Securing client feedback placestherapists in acceleratedcourses of development in thefront of the class to see andhear the lessons of the day—toexperience currentlyexperienced growth.


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Becoming BetterFeedback Is My Compass

• Not an uninhabited terrain oftechnical procedures, nor thepredictable path of diagnosis,prescription, & cure. Cannot bedescribed w/o the client &therapist, co-adventurers in ajourney across unchartedterritory. Common factorsprovide landmarks for thisinterpersonal & idiosyncratic trip,& specific models provide well-traveled directions to consider,but feedback provides thecompass, showing the way tothe desired destination.

For the Love of the WorkOn Becoming a Better Therapist

• If you got into this business, likeme & the majority, because youwanted to help people, youalready have what it takes. Twothings: One is your commitmentto monitor the alliance and theoutcome of the services. Thesecond is your investment inyourself, your own growth anddevelopment. Client feedbackprovides the method for both,the compass for the journey.


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About the Bookand the Webinars

The American Psychological

Association is the publisher

www.apa.org/pubs/books

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

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