Recovery, Consumer Voice, and Lori Ashcraft


Posted in Uncategorized on 02/27/2010 02:06 pm by Dr. Barry Duncan

It just makes a lot of sense for mental health and substance abuse professionals, as Bob Bohanske, Project Leader, asserts in the new edition of the Heart and Soul of Change, to formally partner with consumers and the recovery movement in total. According to SAMSHA:

Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.

Client based outcome feedback (click here for more information or here for free client based outcome and alliance measures) or consumer driven outcomes management gives recipients of our services a real voice in their own care, not just lip service. Therapists and clients could be allies in ensuring that services are recovery oriented (National Consensus Conference on Mental Health Recovery and Mental Health Systems Transformation, 2004)—a shift from professional interventions based on diagnostic labels and prescriptive treatments to individually tailored, consumer-directed services that at their core require clients’ active participation:

The 10 Fundamental Components of Recovery
Self-Direction: Consumers lead, control, exercise choice over, and determine their own path of recovery by optimizing autonomy, independence, and control of resources to achieve a self-determined life. By definition, the recovery process must be self-directed by the individual, who defines his or her own life goals and designs a unique path towards those goals.
Individualized and Person-Centered: There are multiple pathways to recovery based on an individual’s unique strengths and resiliencies as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations. Individuals also identify recovery as being an ongoing journey and an end result as well as an overall paradigm for achieving wellness and optimal mental health.
Empowerment: Consumers have the authority to choose from a range of options and to participate in all decisions—including the allocation of resources—that will affect their lives, and are educated and supported in so doing. They have the ability to join with other consumers to collectively and effectively speak for themselves about their needs, wants, desires, and aspirations. Through empowerment, an individual gains control of his or her own destiny and influences the organizational and societal structures in his or her life.
Holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. Recovery embraces all aspects of life, including housing, employment, education, mental health and healthcare treatment and services, complementary and naturalistic services, addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person. Families, providers, organizations, systems, communities, and society play crucial roles in creating and maintaining meaningful opportunities for consumer access to these supports.
Non-Linear: Recovery is not a step-bystep process but one based on continual growth, occasional setbacks, and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the consumer to move on to fully engage in the work of recovery.
Strengths-Based: Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. By building on these strengths, consumers leave stymied life roles behind and engage in new life roles (e.g., partner, caregiver, friend, student, employee). The process of recovery moves forward through interaction with others in supportive, trust-based relationships.
Peer Support: Mutual support—including the sharing of experiential knowledge and skills and social learning—plays an invaluable role in recovery. Consumers encourage and engage other consumers in recovery and provide each other with a sense of belonging, supportive relationships, valued roles, and community.
Respect: Community, systems, and societal acceptance and appreciation of consumers —including protecting their rights and eliminating discrimination and stigma—are crucial in achieving recovery. Self-acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives.
Responsibility: Consumers have a personal responsibility for their own self-care and journeys of recovery. Taking steps towards their goals may require great courage. Consumers must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness.
Hope: Recovery provides the essential and motivating message of a better future— that people can and do overcome the barriers and obstacles that confront them. Hope is internalized; but can be fostered by peers, families, friends, providers, and others. Hope is the catalyst of the recovery process. Mental health recovery not only benefi ts individuals with mental health disabilities by focusing on their abilities to live, work, learn, and fully participate in our society, but also enriches the texture of American community life. America reaps the benefits of the contributions individuals with mental disabilities can make, ultimately becoming a stronger and healthier Nation.

Resources
www.samhsa.gov

Also check out a great video about recovery at
http://promoteacceptance.samhsa.gov/action/partnersInRecovery.aspx

And speaking of recovery, check out the next webinar:

From Illness to Recovery: Consumer Voice and Choice
A sharp departure from customary discourse on mental illness, recovery-driven services shift away from professional-directed treatment based on diagnostic labels and prescriptive practices to individually tailored, consumer-authored plans. After telling her personal story of recovery, Dr. Ashcraft asserts that moving from illness toward recovery means that counseling professionals must be both responsible and responsive to their customer base and directly involve clients in decision making. This webinar calls for recovery-focused services based on the heart and soul of change—services that recognize clients as the primary movers of change, that require the unique tailoring of intervention to their preferences, and that call for relationships that are collaborative and respectful. Dr. Ashcraft also discusses how to successfully integrate peers into your workforce: peer training and preparation, worksite preparations for a smooth integration of peers, performance improvement approaches for peer work, and evaluation of peer services.

Lori Ashcraft, Ph.D., CPRP is the Executive Director of Recovery Opportunities Center based in Phoenix, Arizona with Peer Support training, consulting and system development operating in 30 states and three countries. Dr. Ashcraft recently served as a professor for the University of Arizona teaching psycho-social rehabilitation and managing one of eight SAMHSA funded employment demonstration programs. Her latest book, Offering Wellness, provides insight to the “whole person” wellness and Recovery approach.

Title: Dr. Lori Ashcraft–From Illness to Recovery: Consumer Voice and Choice

Date: Wednesday, March 10, 2010

Time: 12:00 PM – 1:00 PM CST

Join the members site to enjoy this upcoming webinar here

 

Evidence Based Practice and TF-CBT


Posted in Uncategorized on 02/18/2010 08:29 pm by Dr. Barry Duncan

All approaches have valid explanations and solutions for the problems that clients bring to us. It makes sense to expand our theoretical horizons and learn multiple ways to serve client goals. Similarly, it also makes good clinical sense to be “evidence based” in our work. In truth, no one says, “Evidence, smevidence! It means nothing to my work—I fly by the seat of my pants, meander Willy Nilly through sessions, and rely totally on the wisdom of the stars to show the way.” Saying you don’t believe in the almighty evidence in tantamount to not believing in Mom or apple pie, or whatever your sacrosanct cultural icons happen to be. So what is the controversy about?

On the heels of the American Psychiatric Association’s development of practice guidelines in 1993, to ensure their continued viability in the market, psychologists rushed to offer magic bullets to counter psychiatry’s magic pills—to establish empirically supported treatments (EST). With all good intentions, the task force of Division 12 (Task Force on Promotion and Dissemination of Psychological Procedures, 1995) reviewed available research and catalogued treatments of choice for specific diagnoses based on their demonstrated efficacy in two RCTs. On one hand, the Division 12 Task Force effectively increased recognition of the efficacy of psychological intervention among the public, policymakers, and training programs; on the other hand, it simultaneously promulgated gross misinterpretations—that ESTs have proven superiority over other approaches, and therefore, should be mandated and exclusively reimbursed. Unfortunately, many now believe, to paraphrase Orwell, that some therapies are more equal than others.

The notion, however, that any approach is better than another is indefensible in light of the evidence covered extensively throughout The Heart and Soul of Change that support the outcome equivalence of the different models (the “dodo verdict”) as well as the relative influence of other factors than model and technique. I encourage you to dig a little deeper and bolster your ability to respectfully counter statements that suggest mandates for practice. Littell’s (2010) scathing commentary of ESTs in The Heart and Soul of Change is a good place to start. Littell provides a useful template for understanding the varied ways that findings can be distorted and evidence constructed from underwhelming results.

Like understanding anything else, there is a language involved here and it takes a bit of wading through tedious material. But it is worth it if you desire to counter mandates for specific approaches and promote the freedom for therapists to practice as they see fit according to client preferences and benefit. Our necessary pluralism, the theoretical breadth so important to resonating with clients and accentuating our development, is at stake, as well as our identity—ESTs suggest a therapist identity based on technical acumen in administering manualized, cookie cutter interventions (Duncan & Miller, 2006).

Efficacy over placebo, sham, or no treatment is not efficacy over other approaches, or what is called differential efficacy. In the minority of studies that claim superiority over treatment as usual (TAU) or another approach, you need only to ask one question of the investigation (see Duncan et al., 2004 and Sparks & Duncan, 2010 for a full discussion and examples): Is it a fair contest? Is the study a comparison of two valid approaches intended to be therapeutic administered in equal amounts by therapists who equally believe in what they are doing and who are equally supported to do it—are the therapists from the same pool with equal caseloads or is the experimental group specially selected, trained, and supervised by the researcher/founder of the approach, and have reduced caseloads?

I have never seen an advantage of any approach over another (or TAU) that wasn’t a lopsided contest that had its winner predetermined. Consider Trauma Focused (TF)-CBT, an approach to child sexual abuse that is getting a lot of press as the preferred approach that should be implemented across the board. Let’s look at their “definitive study:” Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402.

SSDD all the way! It is always the same when you scratch below the surface of superiority claims—they just don’t hold up to critical scrutiny. First let me say that there is nothing wrong with TF-CBT. It has good ideas and good possibilities, and is surely helpful for some kids and parents. I just wish they would present it that way; i.e., if you work with kids and families where abuse and trauma are involved, you might consider adding these ideas and interventions to your repertoire—they probably will make some sense to some of your clients. But, of course, that is not what they say and instead they claim superiority and folks get the crazy idea that it should be mandated or practiced exclusively.

As always, you gotta consider whether or not it is a fair contest or one in which the winner is pre-determined by the design (imagine the porpoise and the cow in a swimming contest), the pet approach of the researcher pitted against a less than equal opponent. Child Centered Treatment (CCT), the comparison treatment in this study, is not a fair comparison—it is a sham treatment. Therapists did not see the kids and parents together at all, whereas the TF-CBT therapists saw kids and parents together 3 times out of the 12 possible sessions. It just is not reasonable care of a kid who has been sexually abused without meeting with both the child and parent (or caring adult) together to make sense of what has happened. That’s one thing, and then there is the real kicker: Therapists in the CCT condition did not provide advice or suggestions to kids or parents. This is not a real treatment. In the face of such serious concerns, even the most died in the wool “client centered” therapist would address client requests for suggestions and guidance.

Given this mock therapy, one might also suspect that the therapists likely believed that the TF-CBT offered some advantages over CCT given there was at least some structure and ideas offered to these struggling families. Enter allegiance factors. Therapists served as their own controls (performed both TF-CBT and CCT) and were monitored for fidelity, or other words to ensure they didn’t offer guidance (beyond processing feelings and finding client solutions) in the CCT condition. It doesn’t say who provided the “intensive supervision” but that probably means it was the researchers.

So given that it was an unfair comparison of an active treatment model to one unlikely to ever happen in the real world, and given the therapists in the study could hardly help but like to offer some guidance to clients when asked and therefore likely were more committed to TF-CBT, the results are particularly underwhelming. First off, there was a main effect for both conditions. Both treatments worked, which is a real testament to client factors given the CCT didn’t provide any structure or practical intervention. There were 16 measures for the kids and 4 for the caregivers. 3 of the 16 were clinician rated measures (diagnostic interview by folks trained by the researchers). Of the 16, 8 found a significant advantage for TF-CBT. But 3 of those were the from the clinician’s point of view. Only 5 of 13 client rated measures found an advantage for TF-CBT. All 4 of the adult measures found an advantage for TF-CBT. An inspection of the results table reveals that many of the “significant” findings arise from pretty small differences in the means at post-treatment, challenging at least some of the clinical significance of the findings. Finally, it seems that the measures chosen were reactive, or selected to reflect the very things that TF-CBT directly address while the comparison treatment does not address these aspects at all.

In summary, as always you have to ask yourself when superiority is claimed, “as compared to what?” This is study does not provide compelling evidence that TF-CBT is superior to anything else but rather that TF-CBT has demonstrated that it is a viable way to approach children and families who have suffered the trauma of sexual abuse. Regarding superiority claims, the TF in TF-CBT means totally false!

A summary of the problems often found in such claims can be found at http://heartandsoulofchange.com/resources/handouts/

Thankfully, there is a sanctioned argument to help efforts to rescind mandates for particular approaches. In the face of growing criticism, 2005 APA President Ronald Levant appointed the Presidential Task Force on Evidence-Based Practice (hereafter Task Force). The Task Force defined evidenced based practice (EBP) as “the integration of the best available research with clinical expertise in the context of patient (sic) characteristics, culture, and preferences (Task Force 2006, p. 273). This definition transcends the “demonstrated efficacy in two RCTs” mentality of ESTs and finally makes common clinical sense.

The Task Force also said:
The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential (Task Force, 2006, p. 280).

Proponents from both sides of the common v. specific factors aisle recognized that outcome is not guaranteed regardless of evidentiary support of a given technique or the expertise of the therapist (Anker et al., 2009). Practice based evidence must become routine. The new definition supports an identity of plurality, essential attention to client preferences, a focus on therapist expertise, and the importance of feedback.

Bottom Line: There is nothing wrong with ESTs or evidence based practice. Challenge statements, however, that use evidence based practice to justify mandates, exclusive reimbursement, or dictates about “the” way to address client problems. Know about the dodo verdict and unfair contests in research. Educate others about APA’s definition and the importance of measuring the client’s response to any delivered treatment—advocate for practice based evidence as an evidence based practice.

Next Blog: The Recovery Revolution

 

Drug Emperor Is Naked and John Murphy Webinar


Posted in Uncategorized on 02/01/2010 03:27 pm by Dr. Barry Duncan

Two recent articles highlight the amazing fact that good marketing overcomes bad data every single day of the week. As Jacqueline Sparks (Project Leader) and I and our colleagues say in the new Heart and Soul of Change:

The fact that a for-profit industry plays a role in fashioning what counts as evidence may no longer surprise many. The former editor of the New England Journal of Medicine called attention to the problem of “ubiquitous and manifold . . . financial associations” authors of drug trials had to the companies whose drugs were being studied (Angell, 2000, p. 1516). The result is a direct correlation between who funds the study and its outcome. For example, Heres et al. (2006) looked at published comparisons of five antipsychotic medications. In 9 out of 10 studies, the drug made by the company that sponsored the study was found to be superior…Antonuccio, Danton, and McClanahan, (2003) detail the vast reach of the pharmaceutical industry—from Internet, print, and broadcast media, direct-to consumer-advertising, “grassroots” consumer-advocacy organizations, and professional guilds to medical schools, prescribing physicians, and research—even into the board rooms of the FDA. They conclude, “It is difficult to think of any arena involving information about medications that does not have significant industry financial or marketing influences” (p. 1030). Given the infiltration of industry influence, reliance on press reports, web pages, and even the academic literature as a basis for sound decision-making is unwise. Discerning good science from good marketing requires a willingness to engage primary source material.

Think this is overkill? Think twice. Check out the embedded article “From Evidence-based Medicine to Marketing-based Medicine: Evidence from Internal Industry Documents” written by Glen Spielmans & Peter Parry. Here is the abstract:

While much excitement has been generated surrounding evidence-based medicine, internal documents from the pharmaceutical industry suggest that the publicly available evidence base may not accurately represent the underlying data regarding its products. The industry and its associated medical communication firms state that publications in the medical literature primarily serve marketing interests. Suppression and spinning of negative data and ghostwriting have emerged as tools to help manage medical journal publications to best suit product sales, while disease mongering and market segmentation of physicians are also used to efficiently maximize profits. We propose that while evidence-based medicine is a noble ideal, marketing-based medicine is the current reality.

Here is the article:

Spielmans Parry2010
View more documents from barrylduncan.

And, as a case in point, consider this is true nowhere more than with antidepressants. The slightly better than placebo efficacy of antidepressants has been know for many years. Roger Greenberg and Seymour Fisher exposed antidepressants in their classic 1997 book, From Placebo to Panacea and we reviewed the subsequent literature and reported it (along with several others) as far back as 2000 and 2004 in The Heroic Client as well as the 2000 article, “Exposing the Mythmakers,” which received the All Time Top Ten Award for one of the most influential articles in the Psychotherapy Networker’s history. But yet millions are still prescribed and millions still take them as a first line of defense (nothing against folks who do and surely some benefit). Irving Kirsch, the person who meta-analyzed FDA trials and reported that the antidepressant emperor wore no clothes, has a new book. Check out this article in Newsweek about it: http://www.newsweek.com/id/232781  

Here is a brief summary of Kirsch’s research that we (Sparks, Duncan, Cohen, & Antonuccio) summarize in the new Heart and Soul of Change:

Kirsch and Sapirstein (1998), in a meta-analytic review of nineteen studies involving 2,318 people, showed that 75 percent of the response to antidepressants was duplicated by placebo. They speculated that the remaining 25 percent of the positive antidepressant effect may be attributable to the un-blinding power of side effects. Adding to the critique, Kirsch, Moore, Scoboria, and Nichols (2002) analyzed the efficacy data submitted to the US Food and Drug Administration (FDA) for the six most widely prescribed antidepressants approved between 1987 and 1999. Approximately 82% of the response to medication was duplicated by placebo control groups—57% of the studies failed to show a drug-placebo difference. When a difference was found, the drug/placebo difference was only, on average, 1.8 points on the clinician-rated Hamilton Depression Rating Scale (HDRS). FDA memoranda intimated that the clinical significance of such a small difference was questionable (Laughren, 1998).

In a review of antidepressant trials involving 12,564 persons (Turner, Matthews, Eftihia Linardatos, Tell, & Rosenthal, 2008), 94% of published trials had favorable results whereas the percentage of positive results for published and unpublished trials together drops to 51%. The authors warn that publication bias of this magnitude dramatically distorts reported effect sizes and has serious implications for researchers, health care professionals, and clients. Kirsch et al. (2008) provide further evidence that the belief in antidepressant efficacy is scientifically unfounded. Meta-analytically examining all trials submitted to the FDA for the licensing of four popular SSRIs, the authors found no clinically significant differences between placebo and the drugs, with the exception of the most distressed in the severely depressed group. Even this negligible difference was found to be due not to the drug, but to a decreased response to placebo.

Regarding taking a critical stance about psychiatric drugs, check out the new webiste of the International Critical Psychiatry Network: http://www.criticalpsychiatry.net/  The Heart and Soul Project’s own Certifed Trainer and psychiatrist, Sami Timimi, is a key member. 

On another note, a new webinar by our own John Murphy has been scheduled for February 17:
Respect, Resources, and Recovery: Putting the 3 Rs into Action with Children, Adolescents, and Schools
Wednesday, February 17, 2010, 1:30 to 2:30 Central
Based on the persistent belief that young people and their caregivers are capable of remarkable changes when invited to actively participate in services and to apply their “natural resources” toward solutions, this webinar describes practical ways to put the principles of CDOI and recovery into action in schools, counseling agencies, and other child/youth settings. Real-world examples are used to illustrate the power of partnership and the benefits of client-driven/strength-based practice.

John Murphy, Ph.D., professor of psychology at the University of Central Arkansas, has extensive experience implementing collaborative approaches with young people and school problems (www.drjohnmurphy.com). He recently authored (with Barry Duncan) the book, Brief Intervention for School Problems (2nd ed.) (Guilford, 2007) and Solution-Focused Counseling in Schools (2nd ed.) (2008, American Counseling Association.

John is also a Project Leader of the Heart and Soul of Change Project and a featured speaker at the Heart and Soul of Change Conference in New Orleans. Join John and Barry for this timely discussion of kids and school at: http://www.cdoimembers.com/Default.aspx?pageId=199866

 

Feedback Pioneer Michael Lambert


Posted in Research on 01/15/2010 04:57 pm by Dr. Barry Duncan

Practice based evidence, or the systematic collection of client based outcome feedback, will likely become the rage of the next decade—and for good reason: Feedback pioneer Michael Lambert in his chapter in the just published second edition of the Heart and Soul of Change (2010) reports that effect sizes (ES; a statistical measurement of change) for the difference between feedback and TAU ranges from .34 to .92, unusually large considering that the estimates of the ES of the difference between empirically supported and comparison treatments are about .20. Putting this in perspective, feedback has two to four times the impact of model differences.

Where did this great idea of feedback come from? Howard, Moras, Brill, Matinovich, and Lutz (1996) were the first to advocate for the systematic evaluation of client response to treatment during the course of therapy. When this occurs—when client feedback is systematically collected and used to tailor treatment—good things happen.

For example, using the Outcome Questionnaire 45.2, Michael Lambert really brought this great idea to fruition. He has conducted five RCTs and all five demonstrated significant gains for feedback groups over treatment as usual (TAU) for clients at-risk for a negative outcome. Twenty two percent of TAU at-risk cases reached reliable improvement and clinically significant change compared with 33% for feedback to therapist groups, 39% for feedback to therapists and clients, and 45% when feedback was supplemented with support tools such as measures of the alliance. The addition of client feedback alone, without new techniques or models of treatment and leaving therapists to practice as they saw fit, enabled over two times the amount of at- risk clients to benefit from psychotherapy. Think of the advantage this brings to clinical practice. Systematic feedback allows good outcomes with many of those clients who would otherwise not benefit. 

I am very happy to announce that Michael Lambert, the person most responsible for bringing the power of client feedback to the forefront, will be conducting the next webinar to set the stage for his Heart and Soul of Change conference presentations:

“Yes, It Is Time for Clinicians to Track Outcomes”

Wednesday, January 27, noon to 1:00 Central

Join the person most responsible for the greatest innovation in clinical effectiveness since the beginning of psychotherapy. Register now by joining the CDOI membersite, now over a $400 value for a one year $120 subscription at http://www.cdoimembers.com/

Michael Lambert also inspired our client feedback process, The Partners for Change Outcome Management System’s (PCOMS). PCOMS appeal rests on the brevity of the measures and therefore its feasibility for everyday use in the demanding schedules of front-line clinicians. PCOMS was based on Lambert’s continuous assessment model using the Outcome Questionnaire 45.2, but there are differences beyond the measures. First, PCOMS is integrated into the ongoing psychotherapy process and routinely includes a transparent discussion of the feedback with the client (The Heroic Client). Session by session interaction is focused by client feedback about the benefits or lack thereof of psychotherapy. Second, PCOMS assesses the therapeutic alliance every session and includes a discussion of any potential problems. Lambert’s system includes alliance assessment only when there is a lack of progress. 

Three studies have demonstrated the benefits of client feedback with the ORS and SRS. Miller, Duncan, Brown, Sorrell, and Chalk (2006) explored the impact of feedback in a large culturally diverse sample utilizing a telephonic employee assistance program (EAP). Although the study’s quasi-experimental design qualifies the results, the use of outcome feedback doubled overall effectiveness and significantly increased retention. Two recent RCTs used PCOMS to investigate the effects of feedback versus TAU. First, in an independent investigation, Reese, Norsworthy, & Rowlands (2009) found that clients who attended therapy at a university counseling center or a graduate training clinic demonstrated significant treatment gains for feedback when compared to TAU. Finally, our recent study in Norway (Anker, Duncan, & Sparks, 2009), the largest RCT of couple therapy ever done, found that feedback clients reached clinically significant change nearly four times more than non-feedback couples. The feedback condition maintained its advantage at 6 month follow-up and achieved nearly a 50% lower separation/divorce rate.

A fourth study, a replication of the Norway Feedback Study by Jeff Reese has been submitted and a fifth study addressing feedback in an acute inpatient unit is about to get underway.

Read more on the resources page at http://heartandsoulofchange.com/resources/

 

Oprah Appearance, Bookstore, and New Project Leader


Posted in Uncategorized on 12/27/2009 10:48 am by Dr. Barry Duncan

People have asked me about my appearance on Oprah for many years. It was way back in 1992 just after I published my first book (with my best friend Joe Rock), a self help book called Overcoming Relationship Impasses. (That book, now called “The Lone Changer,” is available as a download at http://heartandsoulofchange.com/resources/bookstore/)

It has always been a source of amusement for me that people are so interested in my brief moment in the spotlight. No matter what I put in my bio, the first thing that is commented on is my Oprah appearance. So in deference to an interest that has mightily stood the test of time, here are snippets of my Oprah debut in the world of TV media. But before you look at it let me say a few words in my defense. I was a full time private practitioner with zero media experience, and I was scared half out of my wits. They called on a Monday and asked me to be there for a Wednesday taping. So I flew up after my last client on Tuesday and checked into a very fancy Chicago hotel, The Drake. I didn’t have a clue about what I was doing. I knew a lot about the book, and a fair amount about working with couples, but nothing about how to handle this situation. The producers for the show, a young and extremely talented  group, were exceptionally helpful and had really done their homework. They really knew the book and asked me very good questions to prepare me for what might happen.  They told me that I had to be very assertive, even aggressive at times (not exactly my style!) and the last thing they wanted me to be was a wallflower. They noted that Oprah would intentionally provoke me, in a nice way, to comment on the action as it unfolded. I was freaked to say the least and rued the day that I ever thought to write a self help book! So here’s the deal: feel free to laugh but not in my face; and please don’t tell me how young I looked (the subtext being how old I look now!)

And one more thing: People often ask me about Oprah. What was she like? She was warm, friendly, and the consumate professional. I have nothing but good things to say about her and her staff. BTW, I have improved (thank goodness) on the TV front. Check out my TV interviews regarding the book What’s Right With You, including a friendly debate with a psychiatrist, at http://www.whatsrightwithyou.com/resources.htm

The bookstore is now open and has all my books including the just published 2nd Edition of The Heart and Soul of Change. More books of interest to the mission of the Project will be added periodically. Full length videos will also soon be featured. Webinars and slideshows are avaliable too. If you have been following the blog and this site, you know that the concept of “recovery” is thematic and a vital part of client directed, outcome informed (CDOI) ideas and practices (http://heartandsoulofchange.com/training/cdoi-members/what-is-cdoi/). I am very happy to say that the theme of recovery also applies to the bookstore. Folks in recovery are running the bookstore and the more products that are sold, the more hours can be offerred. Thanks to Mary Haynes for making this happen and for her ongoing commitment to the values of recovery.

Finally, I am very happy to announce that Anne-Grethe Tuseth is joining our team as a Project Leader. Anne-Grethe is the Leader of the KOR (CDOI) network in Norway and is a long time advocate of CDOI. She first brought me to Norway ten years ago and has been a mover and shaker of the ideas ever since. She orchestrated the first book written about CDOI by others than the developers, was instrumental in translating the Heroic Clients, Heroic Agencies manual into Norwegian, and has been a leader in training others and disseminating  the ideas. In short, Anne-Grethe is a powerful addition to an already incredible group. Find out more about the Project Leaders as well as the CDOI community at http://heartandsoulofchange.com/community/

 

Common Vs Specific Factors: And the Free Webinar


Posted in Research on 12/07/2009 08:29 pm by Dr. Barry Duncan

One of the great controversies in psychotherapy has been the common v. specific factors debate. On one hand, the common factors, or the notion that it is the pantheoretical aspects of providing psychotherapy, those elements common to all (like the alliance) that account for change. On the other hand, the specific factors side argues that there are unique ingredients to particular models of practice that explain how people change in therapy. The common factors side of things enjoys far more empirical support given that no approach has every shown superiority over another, have not ever demonstrated the proposed specific effects, and model differences only account for 1% of the overall variance. It would be great, however, to move beyond the common v specific factors polemics because of course, the factors are intimately intertwined in all ways imaginable. But it is tough when various orientations continue to argue for specific factors in somewhat deceptive attempts to privilege different models. Fact of the matter is you can’t really separate the specific elements of a given model from the context it occurs in (not to mention who is delivering the treatment), or the general effects of delivering any treatment.

Here is how I am writing about the interdependence (excerpted from my new book, On Becoming a Better Therapist): The specific factors (the differences between models) have a relatively small impact but the general effects of delivering a treatment are far more potent. As Jerome Frank (1973) seminally noted, all models include a rationale or myth, an explanation for the client’s difficulties, and a procedure or ritual, strategies to follow for resolving them. Models achieve their effects, in large part, if not completely through the activation of placebo, hope, and expectancy, combined with the therapist’s belief in (allegiance to) the treatment administered. As long as a treatment makes sense to, is accepted by, and fosters the active engagement of the client, the particular approach used is unimportant. Said another way, therapeutic techniques are placebo-delivery devices (Kirsch, 2005).

Allegiance and expectancy are two sides of the same coin—the belief by both the therapist and the client in the restorative power and credibility of the therapy’s rationale and related rituals. When a placebo or technically “inert” condition is offered in a manner that fosters positive expectations for improvement, it reliably produces effects almost as large as a bona fide treatment (Baskin, Tierney, Minami, & Wampold, 2003). The TDCRP is again instructive. First, across all conditions, client expectation of improvement predicted outcome (Sotsky et al., 1991). And second, an inspection of the Beck Depression Inventory scores of those who completed the study (see Elkin et al., 1989) reveals that the placebo plus clinical management condition accounted for nearly 93% of the average response to the active treatments. The act of administering treatment—the model/technique delivered—is the vehicle that carries allegiance and placebo effects in addition to the specific effects of the given approach.

It pays, therefore, to have several rationales and remedies at your disposal that you believe in, as well as believing in the possibility of the client’s ideas about change. Finally, it is important to note that suggesting specific effects are small in comparison to general effects, and that psychotherapy approaches achieve about the same results does not mean that models and techniques are not important. On the contrary, a particular orientation or method may be just the ticket for a given client—while there is no differential efficacy on aggregate, there are approaches that are likely better or worse for the client in your office now.
Bottom Line: The specifics of any approach, either unique to the client or of a particular orientation, are not as important as the cogency of the rationale and ritual to both the client and the therapist, and most importantly, the client’s response to the delivered treatment.

And then there is the alliance context of delivering any specific treatment. The alliance is an all-encompassing framework for psychotherapy—it transcends any specific therapist behavior and is a property of all aspects of providing services (Hatcher & Barends, 2006). The alliance is evident in anything and everything you do—from offering an explanation or technique to address the client’s situation to scheduling the next appointment—to engage the client in purposive work. In an important way, the alliance is dependent on the delivery of some particular treatment—a framework for understanding and solving the problem. The alliance cannot happen without technique (Hatcher & Barends, 2006). If technique fails to engage the client in purposive work, it is not working properly and a change is needed. Think of it this way: Technique is an activity—the alliance is a way to characterize that activity; the alliance is the purpose of the activity (Hatcher & Barends, 2006). Although it is possible for a strong relationship to develop between you and the client, there can be no agreement about the tasks of therapy, a critical aspect of the alliance, without some discussion and negotiation of what “treatment” will be used (Wampold, 2010)—be it some specific approach, the client’s own ideas and cultural preferences, or some unique blend.

The overlapping components of the Venn diagram below depicts the interdependent common factors. There can be no alliance without a treatment, and on the other hand, technique is only as effective as its delivery system—the client-therapist relationship. So you can’t have a good alliance without some agreement about how therapy is going to address the issues at hand. You can’t have purposeful work without collaboration about what that work will entail.

Common Factors
View more presentations from barrylduncan.

Here is where the incredible variety of models and techniques pays off. While there is no differential efficacy among approaches in general, there is differential efficacy among approaches with the client in your office now. The question is: does it resonate or not? Does it fit client preferences? Does its application help or hinder the alliance? Is it something that both you and the client can get behind? You matter here too. If you don’t believe in the potential restorative or healing power of any selected approach—i.e., don’t have allegiance to it—then not much good will come of it. Can you get on board with the client’s notions about how he or she can be helped? Or perhaps some idiosyncratic blend of client ideas, yours, and theoretical/technical ones might ultimately be just the ticket. Your alliance skills are truly at play here: your interpersonal ability to explore the client’s ideas, discuss options, collaboratively form a plan, and negotiate any changes when benefit to the client is not forthcoming. Technique, its selection and application, in other words, are instances of the alliance in action.

So it doesn’t make a whole lot of sense to think of things separately. That is what my hallucinogenic figure tries to portray. BTW, see a full explanation of the common factors diagram on the handouts page:
http://heartandsoulofchange.com/resources/handouts/

And don’t forget to register for the free webinar!

Title: “Dr. Barry Duncan– What in the heck is CDOI? Client Directed, Outcome Informed Ideas and Practices
Date: Tuesday, December 22, 2009
Time: 12:00 PM – 1:00 PM CDT
Register now by clicking the link below:
https://www2.gotomeeting.com/register/326593746

Here are the slides:

What In The Heck Is Cdoi Handouts
View more documents from barrylduncan.

Coming soon: People have asked me about my Oprah appearance for years. On my next blog, I will post the video. The deal is that I am posting it but you are not allowed to laugh about it, at least not to my face!

 

What in the Heck is CDOI? Free Webinar


Posted in Uncategorized on 11/29/2009 08:23 pm by Dr. Barry Duncan

I am doing a free webinar about CDOI. Here is a teaser:

And here is info about the webinar:

“Dr. Barry Duncan – What in the heck is CDOI? Client Directed, Outcome Informed Ideas and Practices”

You might hear folks say CDOI this or CDOI that, and wonder, what in the heck is CDOI?! Client directed, outcome informed services contain no fixed techniques or causal theories regarding the concerns that bring people to treatment. Any interaction can be client-directed and outcome-informed when the consumer’s voice is privileged, social justice is embraced, recovery is expected, and helpers purposefully form partnerships to: (1) enhance the factors across theories that account for success—especially the heart and soul of change; (2) use client’s ideas and preferences (theories) to guide choice of technique and model; and (3) inform the work with reliable and valid measures of the consumer’s experience of the alliance and outcome. This webinar covers the waterfront, from recovery to the common factors to the ORS and SRS—an all in one place description of this thing we call CDOI.

Date: Tuesday, December 22, 2009

Time: 12:00 PM – 1:00 PM CDT

Register now by clicking the link below:

https://www2.gotomeeting.com/register/326593746  

BTW, check out the new resources added to the handouts page: CDOI Fact Sheet, Youth Outcome Management, and Evidence Based Practice Talking Points: http://heartandsoulofchange.com/resources/handouts/

And I wanted to let you know about all the publicity the Norway Feedback Study has received after a press release was sent out by the University of Rhode Island—a co-investigator of the study was Dr. Jacqueline Sparks, faculty in the Department of Human Development and Family Studies.

5 Questions with Dr. Sparks http://www.pbn.com/detail.html?sub_id=46289

New Therapy Technique Reduces Divorce Rates http://ow.ly/162i0O

Professor finds strong link between counseling approach and relationship success: http://www.medicalnewstoday.com/articles/171024.php  

Finally, the Norway Feedback Study also made the Clinician Digest by Garry Cooper in the November edition of the Psychotherapy Networker. Check it out:

http://www.psychotherapynetworker.org/magazine/currentissue/689-clinicians-digest?start=3

I hope you join me for the free webinar.

 

Inspiration, The Twin Cities, and an Interview with Barry


Posted in Uncategorized on 11/19/2009 09:14 am by Dr. Barry Duncan

Just back from an incredible conference of consumers and providers, the 20th annual Children Come First event with the wonderful name: Ready, Set, Relationship! This was the continuing efforts of a group of dedicated individuals, called Wisconsin Family Ties, almost all of whom are parents of special needs children, to give families the support, encouragement, and resources they need to survive and thrive in tough times. They embrace the values of consumer strengths and wisdom as well as the power of change that resides in human relationships. I can’t really say enough about them nor can I express how moved I was to experience their commitment to what they are doing. The director, Hugh Davis, was nothing short of inspirational. He gave up a lucrative career in corporate America to try to make a difference with families who are under exceptional pressures from within because of a special needs child and from without from a system oriented more toward investigation and punishment than helping folks succeed. Constantly fighting an uphill battle for funding, they are making a significant difference in the lives of hundreds of children and families.

Check them out at: http://www.wifamilyties.org/

This is one of the great gifts that I am privileged to receive in my travels, the inspiration of meeting people who have been called to try to make a difference for others. It is heartening to say to least, that people like Family Ties exist. If I become jaundiced at times in my thoughts about we do, these experiences quickly remind me of not only the goodness of people, but also the good of what psychosocial services can accomplish.

On another note, I am doing a workshop in the Twin Cities on February 5th hosted by Rebecca Chesin, another person trying to make a difference in the community. If you are in the Twin Cities area, I would appreciate your support of Rebecca’s efforts. Rebecca recently compiled a list of individuals and agencies who are using client directed, outcome informed practices and is going to expand this idea into an online directory soon. Check out the workshop and the list at:

http://www.timeforclarity.com/cdoitest.html

Finally, another mover and shaker of these ideas is Eric Kueler of Mental Health Pros. Mental Health Pros offers therapists “21st Century tools to optimize psychotherapy for clients.” The 21st Century tools include MyOutcomes, online articles, assessments, multimedia workshops, videos, Lunch and Learn teleseminars, as well as online journaling for clients, practice newsletters, and more.

Check out Mental Health Pros out at: http://mentalhealthpros.com/mhp/ An e-brochure is available at http://mentalhealthpros.com/mhp/pdf/MHPbrochure.pdf

Eric recently interviewed me about the evolution of CDOI ideas and research.

Check it out: Interview with Eric (Download)

Please let me know what you thinking about the blogs. I appreciate your feedback.

 

CDOI Goes Nationwide in Norway


Posted in Uncategorized on 11/04/2009 02:10 pm by Dr. Barry Duncan

Many exciting things are happening in Norway with CDOI. First I was there to help kick off the Bufetat (Child and Family Services Directorate) pilot implementation of 5 family counseling offices which will begin the nationwide rollout of CDOI (called KOR in Norway) in all 64 agencies across Norway. This massive implementation is in great hands with project leader Marianne Bie, and with the able help of Morten Anker, a Heart and Soul of Change Project (HSCP) Certified Trainer, and Geir Skauli a long time CDOIer. This all began back in 2006 when I did a tour of all the family counseling agencies to introduce CDOI (under the visionary leadership of Berger Hareide and Geir Skauli), but the decision to implement was likely cemented by the Norway Feedback Project. Speaking of the Norway Feedback Project, check out this conversation with principle investigator, Morten Anker.

Get the Norway Feedback Article here: http://heartandsoulofchange.com/resources/articles/

Another very cool thing is what RBUP (Child and Adolescent Psychiatric Services) is doing with CDOI training. Under the leadership of Anne-Grethe Tuseth (the person who brought CDOI to Norway), and with the help of Tor Fjeldstad (another HSCP Certified Trainer), a new training program will soon be launched addressing both academic and clinical training. If you have been following this Blog you know that this is part of the mission of the HSCP, to encourage formal inclusion of CDOI in academic and training programs to promote learning of the ideas and practices early in professional careers. This, in a sense, “institutionalizes” the values of client/consumer privilege and true partnerships via outcome and alliance feedback.

Speaking of academia, I was also privileged to share CDOI ideas as well as their integration with therapist development as presented in my upcoming book On Becoming A Better Therapist to a very esteemed group of faculty/practitioners at the University of Oslo. This was arranged by the famous Norwegian Researcher Helge Rønnestad, who along with David Orlinksy, are the premier researchers investigating therapist development and what it means to be therapist. It was quite a thrill for me to present my integration of these ideas before one of the originators. BTW, Professor Rønnestad called the clinical use of the ORS and SRS “operationalized collaboration,” and noted the likely alliance effects of using the measures the way we do with clients.

And of course, that is why I believe that the Norway Feedback Project and Jeff Reese’s feedback article (to be published in December in Psychotherapy) achieved a positive effect with all clients instead of just those clients at risk, as Lambert’s studies mostly do. I believe the way we clinically use the measures in collaboration with clients makes the difference.

Finally, the Norway Feedback Study also made the Clinician Digest by Garry Cooper in the November edition of the Psychotherapy Networker. Check it out:

http://www.psychotherapynetworker.org/magazine/currentissue/689-clinicians-digest?start=3

 

The Good, the Bad, and the Ugly of Psychotherapy


Posted in Uncategorized on 10/19/2009 03:17 pm by Dr. Barry Duncan

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.

 
Older Entries