Those of you who are CDOI Members: http://heartandsoulofchange.com/training/cdoi-members/  know that I just did a webinar of the same title as this blog. For the first time, members were able to download the actual PowerPoint slides from the presentation so that they could influence the decision makers where they work. Here are the slides in pdf format: 

GoodBadUglyWebinarSlides

Here is a brief video I did that covers the main points:

And here is a narrative account excerpted from new book, On Becoming a Better Therapist:
The good news is that the efficacy of psychotherapy is very good—the average treated person is better off than about 80% of the untreated sample (Duncan, Miller, Wampold, & Hubble, 2010), translating to an effect size (ES) of about 0.8. Moreover, these substantial benefits apparently extend from the laboratory to everyday practice. For example, a real world study in the UK (Stiles, Barkham, Twigg, Mellor-Clark, & Cooper, 2006) comparing cognitive behavioral therapy (CBT), psychodynamic therapy (PDT), and person centered therapy (PCT) as routinely practiced reported a pre-post ES of around 1.30. In short, there is a lot to feel proud about our profession: psychotherapy works.

But there’s more to the story. The bad news is two-fold: First, drop outs are a significant problem in the delivery of mental health and substance abuse services, averaging at least 47% (Wierzbicki & Pekarik, 1993). When drops outs are considered, a hard rain falls on psychotherapy’s efficacy parade, both in randomized clinical trials (RCT) and in clinical settings. Second, despite the fact that the general efficacy is consistently good, not everyone benefits. Hansen, Lambert, and Foreman (2002), using a national data base of over 6000 clients, reported a sobering picture of routine clinical care in which only 20% of clients improved as compared to the 57-67% rates typical of RCTs. Whichever rate is accepted as more representative of actual practice, the fact remains that a substantial portion of clients go home without help.

And the ugly: Explaining part of the volatile results, variability among therapists is the rule rather than the exception. Not surprisingly, although rarely discussed, some therapists are much better at securing positive results than others. In fact, therapist effectiveness ranges from 20-70%! Moreover, even very effective clinicians seem to be poor at identifying deteriorating clients. Hannan et al. (2005) compared therapist predictions of client deterioration to actuarial methods. Though therapists were aware of the study’s purpose, familiar with the outcome measure used, and informed that the base rate was likely to be 8%, they accurately predicted deterioration in only one out of 550 cases; 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, 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 know how effective we really are—we don’t know who will drop out or who will ultimately not benefit or even deteriorate. Do you know how effective you are? With drop outs considered, how many of your clients leave your office absent of benefit? Which clients in your practice now are at risk for drop out or negative outcome?

And what is the answer to these problems? You know! Practice based evidence. Continuous client feedback individualizes psychotherapy based on treatment response, provides an early warning system that identifies at risk clients thereby preventing drop-outs and negative outcomes, and suggests a tried and true solution to the problem of therapist variability—namely that feedback necessarily improves performance and quickens the pace of your development.

I just did a brief video (see below) for the Louisiana Counseling Association’s Annual Conference to invite folks to the Heart and Soul of Change Conference occurring June 17-19 in perhaps the most exciting city in North American, New Orleans. http://heartandsoulofchange.com/training/heart-and-soul-of-change-conference/  That reminded me to blog more about the details.

Heart and Soul of Change, New Orleans

The conference will be just a stone’s throw away from the French Quarter at the InterContinental Hotel http://www.ichotelsgroup.com/intercontinental/en/gb/locations/neworleans and I am very happy to say that the room rate was negotiated to be a very reasonable $119 per night. Check out the video tour of the hotel and what New Orleans has to offer. We want you to get the most out of your visit, not only with regard to the quality of the presenters and the stellar training opportunity this conference offers, but also your experience of this spectacular city. Consequently, lunch breaks will be a full two hours so that you can explore the amazing culinary experiences awaiting you in the French Quarter. New Orleans is such an historical, festive, musical, culinary, cultural place that you have to experience firsthand to appreciate it.

Another reason this conference is exciting for me is that I will be presenting my five steps to accelerate your development as a therapist that I detail in my new book, On Becoming a Better Therapist due out in March. Here is a brief description. The five steps build on the lessons I’ve learned from incorporating feedback in my work and helping others do it, but also integrates research about therapist development. A pre-requisite is your understanding that you are a primary figure in each client’s ultimate outcome—the client is certainly central, but as the old saying goes, it takes two to tango. Your view of your growth impacts your ability to be vitally involved in the therapeutic process. Collecting outcome feedback begins the process. The first step is to track your cumulative career development and take it on as a project. Proactively monitor your effectiveness in service of implementing strategies to improve your outcomes. Practice the skills of your craft and monitor your results.

Next, deliberately expand your theoretical repertoire and loosen your grip on the inherent truth value of any given approach. Take multiple vantage points on your journeys with clients while you search out different understandings of client dilemmas. Plurality of perspective serves you and your clients. Theoretical breadth enriches the therapeutic process while simultaneously increasing your involvement in and satisfaction with the work. Third and most importantly, pay close attention to your currently experienced growth. Take a step back, review your current clients and consider the lessons you are learning. Empower yourself, like you would your clients, to enable the lessons to take hold and add meaning to your development as a therapist. Articulate how client lessons have changed you and your work, and what it means to both your identity as a helper and how you describe what it is that you do.

Fourth, continuing that theme, reflect about your identity and construct a story of your work that captures what you do as a helper. Continue to edit and refine your identity and accounts of what constitutes the essence of your work—evolve a description that you can have allegiance to but that doesn’t lead to dead ends. Finally, accumulate the gems of your experiences with clients and the gifts of their feedback, and secure them safely in your Treasure Chest. The Treasure Chest is the place to go to escape tough times and reconnect to the work, to why you become a therapist in the first place. It is also the place to record, through your clients and your own narrative accounts, your development as a therapist. To learn more about the five steps, subscribe to CDOIMembers at http://heartandsoulofchange.com/training/cdoi-members/

Bottom Line: If you got into this business, like me and the majority of therapists I meet, because you wanted to help people, you already have what it takes to become a better therapist. It boils down to two things: One is your commitment to forming partnership with clients to monitor the alliance you have with them and the outcome of the services you are providing. The second is your investment in yourself, your own growth and development. Systematic client feedback provides the method for both.

Rebecca just posted this article on the Heroicagency Listserv, and as she said, it begged a response.

Ignoring the Evidence
Why do psychologists reject science?
By Sharon Begley | NEWSWEEK

Published Oct 2, 2009

From the magazine issue dated Oct 12, 2009

It’s a good thing couches are too heavy to throw, because the fight brewing among therapists is getting ugly. For years, psychologists who conduct research have lamented what they see as an antiscience bias among clinicians, who treat patients. But now the gloves have come off. In a two-years-in-the-making analysis to be published in November in Perspectives on Psychological Science, psychologists led by Timothy B. Baker of the University of Wisconsin charge that many clinicians fail to “use the interventions for which there is the strongest evidence of efficacy” and “give more weight to their personal experiences than to science.” As a result, patients have no assurance that their “treatment will be informed by science.” Walter Mischel of Columbia University, who wrote an accompanying editorial, is even more scathing. “The disconnect between what clinicians do and what science has discovered is an unconscionable embarrassment,” he told me, and there is a “widening gulf between clinical practice and science.”

The “widening” reflects the substantial progress that psycho-logical research has made in identifying the most effective treatments. Thanks to clinical trials as rigorous as those for, say, cardiology, we now know that cognitive and cognitive-behavior therapy (teaching patients to think about their thoughts in new, healthier ways and to act on those new ways of thinking) are effective against depression, panic disorder, bulimia nervosa, obsessive-compulsive disorder, and -posttraumatic-stress disorder, with multiple trials showing that these treatments—the tools of psychology—bring more durable benefits with lower relapse rates than drugs, which non-M.D. psychologists cannot prescribe. Studies have also shown that behavioral couples therapy helps alcoholics stay on the wagon, and that family therapy can help schizophrenics function. Neuroscience has identified the brain mechanisms by which these interventions work, giving them added credibility.

You wouldn’t know this if you sought help from a typical psychologist. Millions of patients are instead receiving chaotic meditation therapy, facilitated communication, dolphin-assisted therapy, eye-movement desensitization, and well, “someone once stopped counting at 1,000 forms of psychotherapy in use,” says Baker. Although many treatments are effective, they “are used infrequently,” he and his coauthors point out. “Relatively few psychologists learn or practice” them.

Why in the world not? Earlier this year I wrote a column asking, facetiously, why doctors “hate science,” meaning why do many resist evidence-based medicine. The problem is even worse in psychology. For one thing, says Baker, clinical psychologists are “deeply ambivalent about the role of science” and “lack solid science training”—a result of science-lite curricula, especially in Psy.D. programs. Also, one third of patients get better no matter what therapy (if any) they have, “and psychologists remember these successes, attributing them, wrongly, to the treatment. It’s very threatening to think our profession is a charade.”

When confronted with evidence that treatments they offer are not supported by science, clinicians argue that they know better than some study what works. In surveys, they admit they value personal experience over research evidence, and a 2006 Presidential Task Force of the American Psychological Association—the 150,000-strong group dominated by clinicians—gave equal weight to the personal experiences of the clinician and to scientific evidence, a stance they defend as a way to avoid “cookbook medicine.” A 2008 survey of 591 psychologists in private practice found that they rely more on their own and colleagues’ experience than on science when deciding how to treat a patient. (This is less true of psychiatrists, since these M.D.s receive extensive scientific training.) If they keep on this path as insurers demand evidence-based medicine, warns Mischel, psychology will “discredit and marginalize itself.”

If public shaming doesn’t help, Baker’s team suggests a new accreditation system to “stigmatize ascientific training programs and practitioners.” (The APA says its current system does require scientific training and competence.) Two years ago the Association for Psychological Science launched such a system to compete with the APA’s.

That may produce a new generation of therapists who apply science, but it won’t do a thing about those now in practice.

Find this article at
http://www.newsweek.com/id/216506

My Response
There are many inaccuracies in this story—not the least of which is the distortion of APA’s definition of evidence based practice, which unequivocally does not give equal weight to the personal experiences of the clinician and scientific evidence—but I will focus here on the “evidence” claiming that the noted approaches are the most effective. Perhaps clinicians are ignoring the researchers quoted in the article because the brand of evidence they are selling is not credible or relevant to their work. They fail to mention the most replicated piece of evidence in the psychological literature: Namely, that no one treatment model, including the cognitive and cognitive behavioral models canonized in the article, have reliably shown any superiority over other treatments. Moreover, treatment models account for a very small amount of the variance of change. As just one example of these robustly demonstrated findings, consider the landmark NIMH study of depression in which cognitive behavioral therapy was compared to interpersonal therapy and antidepressants. No differences emerged between the treatments—they all worked about the same (although the talk therapies did better at follow-up). Treatment model differences accounted for only 2% of variance of change. What did explain the changes achieved by the clients? The quality of the relationship/alliance between the clinician and the client accounted for 21% of the variance. The person of the clinician, not what treatment was delivered explained another 8%. This is why clinicians don’t rally around the flag of different treatments making false claims about superior effectiveness. They know that other factors are far more important—psychotherapy is a richly nuanced interpersonal event that defies being reduced to a diagnosis and treatment model.

The much ballyhooed models have only shown themselves to be better than sham treatments or no treatment at all, which is not exactly news to write home to mom about. Think about it. What if one of your friends went out on a date with a new person, and when you asked about the guy, your friend replied, “He was better than nothing—he was unequivocally better than watching TV or washing my hair.” (Or, if your friend was a researcher: “…he was significantly better, at a 95% confidence level, than watching TV or washing my hair). How impressed would you be?

Finally, the success of any treatment is not guaranteed regardless of its evidentiary support or the expertise of the therapist. As the APA Task Force noted, the response of the client is variable and therefore must be monitored and treatment tailored accordingly to ensure a positive outcome. Monitoring outcome with clients, what has been called practice based evidence, has been shown to significantly improve treatment outcomes regardless of the treatment administered, a far more powerful influence on outcome that the specific approach administered.