I have been thinking about and writing about the common factors and their operationalization for many years. Research continues to build a compelling case for the presence of pantheoretical factors in operation that overshadow any perceived or presumed differences among approaches. For example, our alliance article soon to be published in the Journal of Consulting and Clincal Psychology found the alliance to be predictive of outcome over and above early treatment change and our in preparation investigation of therapist effects found that differences among therapists were best explained by their alliance abilities–over gender, discipline, or experience (more on both of these studies later). Some of you may have seen my depiction of the factors shown below:

I am always striving to describe the factors in a way that illustrates their interdependence. Here is my latest effort: Five factors comprise this perspective: client, therapist, alliance, the model/technique delivered, and feedback—all interdependent and overlapping. Technique is the alliance in action, carrying an explanation for the client’s difficulties and a remedy for them—an expression of the therapist’s belief that it could be helpful in hopes of engendering the same response in the client. Indeed, you cannot have an alliance without a treatment, an agreement between the client and therapist about how therapy will address the client’s goals. Similarly, you cannot have a positive expectation for change without a credible way for both the client and therapist to understand how change can happen. And the only way to know whether the common factors are in operation is to obtain real time client feedback about the benefit and fit of services. Feedback overlaps with and affects all the factors—it is the tie that binds them together—allowing the common factors to be delivered one client at a time. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitoring of outcome, heightens hope for improvement, fits client preferences, maximizes therapist-client fit, and is itself a core feature of therapeutic change.

And I believe the only way to fully understand the importance of the common factors, including feedback, is to see them in action with real clients. Consequently, a new feature has been added to CDOI Members: actual client videos (client idenities are protected) are now available to Members for anytime viewing and learning.

Also, please check out the free webinars about my new book, On Becomng a Better Therapist. They are posted as they occur on the Video page, and the pdf of the slides as well as the videos are posted on the discussion page.

Finally, check out the following video made by Robyn Pope, a certified CDOI trainer of the Heart and Soul of Change Project, of staff at Wesley Community Action.  Wesley is a broad based social service agency that provides culturally sensitive and socially just services in non traditional settings. Robyn solicits staff reactions about the use of the Outcome Rating Scale and Session Rating Scale, including how they have grown professionally and personally as well as the challenges they have faced in implementation.

Clients are indeed the best teachers. The following client, Peter, taught me about the importance of soliciting client ideas about what might be helpful or what I later called “the client’s theory of change.” This is an excerpt from On Becoming a Better Therapist:

When I was an intern, I worked in an outpatient unit euphemistically called the “Specialized Adult Services” unit. While about a fifth of my referrals came from a stress management program, it was really an aftercare facility devoted to working with clients with the moniker “severely mentally ill.” By that time, I had acquired experiences in two CMHCs and an assessment/therapy stint in the state hospital. But the hospital experience lingered, leaving me with a bad taste in my mouth. I saw firsthand the facial grimaces and tongue wagging that characterize the neurological damage caused by antipsychotics and sadly realized that these young adults would be forever branded as grotesquely different, as “mental patients.” I witnessed the dehumanization of people reduced to drooling, shuffling zombies, spoken to like children and treated like cattle. I barely kept my head above water as hopelessness flooded the halls of the hospital, drowning staff and clients alike in an ocean of lost causes. I could not even imagine what it would have been like to live there in the revolving door fashion that many were forced to endure. Now, in my internship position, my charge was to help people stay out of the hospital, and I took that charge quite seriously.

One of my first clients was Peter. Peter was not very liked at the SAS unit. He sometimes said ominous things to other clients in the waiting room, or often spoke in a boisterous way about how the florescent lights controlled his thinking through a hole in his head. When he wasn’t speaking, he grunted and squealed and made other sounds like a pig. As a new intern, I was put under considerable pressure to address Peter’s less than endearing behaviors, particularly because he sometimes offended the stress management clients, who were seen as coveted treasures not to be messed with. Actually, I found Peter to be a terrific guy with a very dry sense of humor, but a man of little hope who lived in constant dread of returning to the state hospital. His behaviors were mostly his efforts to distract himself from tormenting voices that told him that people were trying to kill him and other scary things.

Peter’s unfortunate routine was that he was terrorized by these voices until he started taking actions that would ultimately wind him up in the state hospital. He might empty his refrigerator for fear that someone had poisoned his food, creating a stench that would soon bring in the landlord and ultimately the authorities. Or, occasionally he would start threatening or menacing others, those he believed were trying to kill him. One time he took an empty rifle and perched on an overpass trying to figure out who was on their way to kill him, thinking he could ward them off. Once hospitalized, his medications were changed, usually increased in dose, and he essentially slept out the crisis. These cycles occurred about every four to six months and had so for the last eight years. Peter’s treatment brought with it tardive dyskinesia and about a hundred pounds of extra weight.

Peter hated the state hospital and I could truly commiserate, after my less than inspiring experience there. I felt profoundly sad for this young man, who was about the same age as me. I also felt completely helpless. Nothing in my training provided any guidance. I had no clue about what to do to be helpful to him. I was trying to apply strategies I learned from my supervisor about addressing the voices, which were helpful to others, but not with Peter. I knew he was ramping up for another admission—he told me that he had already emptied his refrigerator and left it on the kitchen floor. I hit a brick wall. It seemed that nothing I said could convince Peter to get off the merry go round to the state hospital. The anguish in his eyes about his impending hospitalization haunted me.

Only because I had no clue about what to do, I asked Peter what he thought it would take to get a little relief from his situation—what might give him just a glimpse of a break from the torment of the voices and the revolving door hospitalizations. After a long pause, Peter said something very curious—he said that it would help if he would start riding his bike again. This led to my inquiry about the word “again.” Peter told me about what his life was like before the bottom fell out. Peter had been quite the competitive cyclist in college and was physically fit as only world class cyclists can be. I heard the story of a young man away from home for the first time, overwhelmed by life, training day and night to keep his spot on the racing team, and topped off by falling in love for the first time. When the inevitable came to pass and the relationship ended, it was too much for Peter, and he was hospitalized, and then hospitalized again, then hospitalized again, and so on until there was no more money or insurance—then the state hospitalization cycles ensued.

On a roll now and enjoying a level of conversation not achieved before, I asked Peter what it would take to get him going again on his bike. He said that his bike was in need of parts and what he needed was for me to accompany him to the bike shop. Peter was afraid to go out in public alone for fear of threatening someone and ending up in the hospital. I immediately consulted with my supervisor who had the good sense here (and on many occasions) to give me an enthusiastic green light. The next day, I went with Peter to the bike shop, where I, bought a bike as well. Peter and I started having our sessions biking together. Peter still struggled with the voices at times, but he stayed out of the hospital and they never kept him from biking. He eventually joined a bike club and moved into an unsupervised living arrangement.

You can read a lot of books about schizophrenia and its treatment but you’ll never find one that recommends biking as a cure. And you can read a lot of books about treatments in general, and you’ll never read a better idea about a client dilemma than will emerge from a client in conversation with you—a person who cares and wants to be helpful.

The first Discussion Webinar covering Chapter One of On Becoming a Better Therapist is history. It was a great discussion and lots of fun. Over a hundred folks joined me for a lively Q and A.  Watch the video of the Chapter One Discussion and enjoy some great comments and questions.

Here is the description of the free webinar series and the details of the Chapter Two Webinar on August 26.

Most of us became therapists because we wanted to be helpful to other human beings, and most of us carry an inextinguishable passion to become better at it. But how do we get better? The truth is that although we are painfully aware that some clients clearly don’t benefit while others inexplicably end therapy, we don’t know how effective we really are or what we can do to improve our outcomes. Despite our hard work and good intentions, unfruitful encounters with clients combined with the confusing cacophony of “latest” developments can weigh on us, steer us into ruts, and make us forget why we became therapists to begin with. How can we remember our original aspirations, continue to develop as therapists, and achieve better results, more often, with a wider variety of clients? In short: how can you become a better therapist?

On Becoming answers that question in a pragmatic and clinically nuanced way, presenting a five-step method of integrating outcome management with therapists’ long-term professional development. In this second of seven webinars corresponding to the seven chapters of the book, I will present a 15 minute overview of the second chapter followed by your questions, comments, and reflections. My hope is that the book and these discussions will inspire you to rediscover purpose in your work and become a better therapist.

Hope you can make the next one: August 26, 6-7:30PM. Register now at: https://www2.gotomeeting.com/register/525541291

Remember, it’s free! If you can’t make the live event, each discussion will be posted for your anytime watching pleasure at: http://heartandsoulofchange.com/on-becoming-a-better-therapist-free-discussion-webinars/