Weiss, R., et al. (2012). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence. Archives of General Psychiatry, 68 (12), 1238-1246.

This is an interesting article and on first pass, it seems like a reasonable look at the relative merits of medication management with buprenorphine-naloxone (Suboxone) v. the same with an additional counseling component. But on further inspection, the spin on the results is an unabashed marketing of Suboxone to primary care docs. First, and foremost, the results are simply atrocious. The study had 2 phases: a two week “treatment lite” version (2 weeks of meds with a 2 week taper off the med followed by a 7 week follow up) and an up to 24 week more intensive regimen (12 weeks of meds followed by a 3 week taper and a 7 week follow up). In the first phase, only 6.6% of participants achieved successful outcomes; in the second phase, only 8.6% achieved a successful outcome. Holy Cow! The additional counseling mattered not: no differences in outcome between conditions. But before I get to that, and there is likely a pretty good reason for it, let’s address the spin on this study.

In the second phase, following 12 weeks of the meds (of course you know this an opioid agonist that approximates but does not offer the full package of actual opioid use because of the addition of a one quarter antagonist), there was a 49.2% successful outcome which all but evaporated after the med was tapered off. So the spin is that as long as you keep prescribing the Suboxone, nearly half of patients will successfully stay off prescription opioids. But if you stop, nearly all of those who benefit will ultimately start using again. So Suboxone, in essence, and without saying it directly, is promoted as a life-long treatment for opioid addiction that any physician can do in primary practice. A scary thought to be sure, and certainly a conclusion that benefits you know who. That’s the spin. But what won’t be in the sound bites here is that the medication management condition included weekly appointments with docs and weekly discussion of addiction, abstinence, and other psychiatric and substance abuse issues as well as the recommendation of self help groups. So the medication management condition already included a counseling component, although a less intensive one—a 20 minute meeting as opposed to the 60 minute meetings in the counseling condition. It is not likely that primary care physicians in the real world would every do the medication management component of the treatment and would wind up just prescribing the Suboxone, which is likely the bottom line message here.

Now, I am not saying that counseling added anything better because it didn’t. It seems like the counseling was pretty much the traditional, psychoeducational medical model, 12 step variety with a skill building component around life skills and relapse prevention. It just didn’t add much to what the doc provided and perhaps was seen as superfluous by the patient after talking to the doc and getting the drug. In essence it was counseling lite (by a doc who is giving you drugs) vs. a more intensive counseling experience. I wonder what giving the drug v. therapy would have done. I don’t think it was a very good effort to show what therapy can provide a person with an opioid addiction .

Several take home points: first of all opioid addiction (oxycodone, hydrocodone, hydromorphone, morphine, codeine, propoxyphene, etc), virtually created by free prescribing practices of primary care docs and anesthesiologists for pain etc, promoted heavily by drug companies is perhaps the mother of all addictions in terms of difficulty to treat. It exceeds heroin addiction in scope by at least 20 times. Perhaps it is the ultimate irony that the treatment advocated is to be administered by the same primary care docs who got us into this mess to start with. So the pharmaceutical industry has created this monster problem and now has a solution for it. I hope that we can figure out a better way than keeping a person on Suboxone. Because, besides the less than exemplary results, 83% experienced 1 or more adverse events in Phase 1 and 60% in Phase 2 (most common were headache and constipation). It is interesting that percentages of all the side effects are presented until we get to the “serious adverse events (SAE).” In Phase1, there were 12 SAEs (just 2 weeks of med treatment) or 1.8% experienced an SAE but when the med treatment continued for 12 weeks, 6.7% of patients experienced a severe adverse reaction. So the risks increase as time on the meds increase.

It is a complicated picture of a very difficult problem. Call me jaded but it is hard for me to not to see this article (whose authors have many ties to pharmaceuticals) as purely a marketing effort.

That’s my take.

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So I think students need to understand the value of treatment models within a developmental context and an understanding of the general aspects that models bring to the table.

The next larger context is the alliance. 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. If technique fails to engage the client in purposive work, it is not working properly and a change is needed. Technique is an activity—the alliance is a way to characterize that activity; the alliance is the purpose of the activity. Although it is possible for a strong relationship to develop, 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—be it some specific approach, the client’s own ideas and cultural preferences, or some unique blend.

The issue of resonance and the agreement about tasks—finding a framework for therapy that both the therapist and the client can believe in—is why it makes a lot of sense to ask clients about their ideas about how to proceed, or at the very least getting client approval of any intervention plan. Not surprisingly, Frank and Frank (1991) said it best: “Ideally, therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem’’ (p. xv). But Frank was not the first and in fact the idea of matching client preferences and worldview goes back to Paul Hoch, Milton Erickson, and the MRI. Traditionally, such a process has not been the case—the search has been for interventions that promote change by validating the therapist’s favored theory. Serving the alliance requires taking a different angle—the search for ideas that promote change by validating the client’s view of what is helpful—or what I have called, based on the work of Erickson and the MRI, the client’s theory of change (Duncan et al., 1992; Duncan & Moynihan, 1994). Here is an article about the client’s theory of change:

Finally, the third context is regarding evidence based treatment itself and the difference between evidence based treatments and evidence based practice as defined by APA. Jeff Reese and I recently wrote a chapter about this and I will post it after it is published. They are two fundamentally different approaches to defining and disseminating evidence (Littell, 2010; see her chapter in Heart and Soul of Change)—one that seeks to improve clinical practice via the dissemination of treatments meeting a minimum standard of empirical support (EBT) and another that describes a process of research application to practice that includes clinical judgment and client preferences (EBP). That psychotherapists might possess the psychological equivalent of a “pill” for emotional distress resonates strongly with many, and is nothing if not seductive as it teases the desire to be as helpful as possible to clients. A treatment for a specific “disorder,” from this perspective, is like a silver bullet, potent and transferable from research setting to clinical practice. Any therapist need only load the silver bullet into any psychotherapy revolver and shoot the psychic werewolf stalking the client. This is the essence of an EBT approach, characterized by Division 12, depicting confidence in the available evidence and appealing to those who believe that more structure and consistency and less clinician judgment is needed to bring about positive outcomes in mental health and substance abuse services. On the other hand, EBP reflects the understanding that scientific evidence is tentative and that outcome is dependent not only on applying the various types of empirical research but also on the participants. EBP appeals to those who value clinician autonomy and individualized treatment decisions based on unique presentations of clients. The APA Task Force definition on EBP exemplifies this approach to the evidence: “the integration of the best available research with clinical expertise in the context of patient [sic] characteristics, culture, and preferences” (APA Task Force 2006, p. 273).
The first part, “the integration of the best available research,” includes the consideration of EBTs without privileging them, as well as the wide range of findings regarding the alliance and other common factors. Next, “with clinical expertise,” in contrast to the EBT mentality of the therapist as an interchangeable part, brings the therapist into the equation—highlighting what therapists bring is consistent with emerging research about the importance of clinician variability to outcome. Moreover, the Task Force submitted: “Clinical expertise also entails the monitoring of patient progress…” (APA, 2006, p. 276–277). Finally, “in the context of patient characteristics, culture, and preferences” rightfully emphasizes what the client brings to the therapeutic stage as well as the acceptability of any intervention to the client’s expectations, how well any model or technique resonates. In short, EBP accommodates the common factors, reinforces the importance of the therapist and client, and includes client feedback as a necessary component.

So if these larger contexts of understanding EBTs are included, I believe that EBTs should be taught in graduate training programs. Graduate training should call for a more sophisticated and empirically informed clinician who chooses from a variety of orientations and methods to best fit client preferences and cultural values. Although there has not been convincing evidence for differential efficacy among approaches, there is indeed differential effectiveness for the client in the room now—therapists need expertise in a broad range of intervention options, including evidence based treatments, but must remember that the proof of the pudding is in the taste.

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PHILADELPHIA (3/6/12) – On Saturday, May 5, 2012, as thousands of psychiatrists congregate in Philadelphia for the American Psychiatric Association (APA) Annual Meeting, individuals with psychiatric labels and other supporters will converge in a global campaign to oppose the APA’s proposed new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), scheduled for publication in May 2013.

Occupy the APA will include distinguished speakers from 10 a.m. to noon at Friends Center (1515 Cherry Street, Philadelphia). A march at 1 p.m. from Friends Center will lead to the Pennsylvania Convention
Center (12th and Arch Streets), where the group will protest beginning at 1:30 while the APA meets inside.

“This peaceful protest exposes the fact that the DSM-5 pushes the mental health industry to medicalize problems that aren’t medical, inevitably leading to over-prescription of psychiatric drugs -including for people experiencing natural human emotions, such as grief and shyness,” said David Oaks, founder and director of MindFreedom International (MFI), which has worked for 26 years as an independent voice of survivors of psychiatric human rights violations. “We call for better ways to help individuals in extreme emotional distress.”

Other speakers criticizing the revised manual, considered the psychiatric industry’s bible, include Brent Robbins, Ph.D., Secretary of the Society for Humanistic Psychology, which has gathered more than
8,000 signatures from mental health professionals calling for “developing an alternative approach” to the DSM.

Jim Gottstein, Esq., founder and president of the Alaska-based Law Project for Psychiatric Rights (PsychRights), will cross the country to speak. “The public mental health system is creating a huge class of chronic mental patients through forcing them to take ineffective yet extremely harmful drugs. As the APA gets ready to do even more harm with its proposed expansion of what constitutes mental illness, I want to be there in person to participate in the protest.”

Occupy the APA will begin at 10 a.m. at Friends Center (1515 Cherry Street, Philadelphia), where the speakers will also include:
• Dr. Paula Caplan, a psychologist, playwright and activist from California;
• Dr. Al Galves, director of the International Society for Ethical Psychology & Psychiatry (ISEPP);
• Joseph Rogers, chief advocacy officer of the Mental Health Association of Southeastern Pennsylvania (MHASP); and
• Dr. Stefan P. Kruszewski, a whistleblower who was fired by the Pennsylvania Department of Public Welfare after he reported the abuse and deaths of Pennsylvania children as a result of systemic physical
and psychiatric malfeasance. His subsequent federal lawsuit was successfully settled in 2007.

“We will promote humane alternatives to the traditional mental health system, such as peer support, which evidence proves is effective in helping individuals recover from severe emotional distress,” Oaks said. “Our protest is about choice, and everyone is welcome.”

On another note, here is a review of On Becoming a Better Therapist (watch a free series of webinars about On Becoming) that appeared in Psychotherapy.

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2. Why, given all the time, money, and other resources dedicated to assessing outcomes in behavioral health, is there not a widespread adoption and implementation of outcome measurement?
There are a few reasons. First it hasn’t been a part of the vernacular of our field at the clinician level. For anyone in the field for a few years, it is a totally foreign concept and most folks assume the best regarding effectiveness. It is critical that graduate education step up to plate here and groom a new generation of mental health/substance abuse professionals that are savvy about outcome informed practice. Second, the field has not provided clinicians with any feasible, clinician friendly way to manage outcomes until recently. Some have been turned off by cumbersome and lengthy measures designed by researchers that don’t appear to be related to the day-to-day work of the front line therapist. Finally, many are afraid because of all the talk about P4P and other ideas that suggest that some will be punished who do not measure up to some arbitrary standard. The whole process of outcome measurement and management need to makes sense to front line therapists and appeal to their nearly universal desire to do good work and get better over the course of their careers. That is why the implementation process of the Project emphasizes both a top down and bottom process. It includes attention to things that makes sense to therapists: 1) common factors; 2) a nuanced clinical process; 3) and therapist development.

The common factors, those elements of psychotherapy running across all models that account for change (Duncan, 2010; Duncan et al., 2010), provide an overarching framework for the PCOMS intervention. Integrating the use of PCOMS within the larger literature about what works in therapy promotes therapist understanding of the feedback process and adherence to the feedback protocol. PCOMS is presented as the tie that binds these healing components together, allowing the factors to be expressed 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 chances for a strong alliance, and is itself a core feature of therapeutic change (Duncan, 2010).

Although the over 300,000 administrations of the measures has yielded invaluable information regarding the psychometrics of the measures, trajectories, algorithms, etc., PCOMS remains a clinical intervention embedded in the complex interpersonal process called psychotherapy. For successful implementation and ongoing adherence, PCOMS must appeal to therapists at a clinical level in ways that the numbers or data or even the research never can. Consequently, PCOMS is described as the clinical process that it is—one that requires skill and nuance to achieve the maximum feedback effect. PCOMS speaks to therapists “where they live” by providing a methodology to address those clients who do not benefit from their services.

Similarly, a focus on therapist development provides a positive motivation for therapists to invest time and energy in PCOMS. There will always be organizational motivations for PCOMS in terms of improved outcomes and reduced costs–the language of “return on investment” and “proof of value.” But there is also the personal motivation of the therapist, the very reason most got into this business in the first place: to make a difference in the lives of those served. The groundbreaking research by Orlinsky and Rønnestad (2005) about therapist development (now over 11,000 therapists included) demonstrates that nearly all therapists want to continue to improve throughout their careers and harnessing this motivation is part and parcel to successful implementation. PCOMS appeals to the best of therapist intentions and encourages therapists to collect ORS data so that they can track their development and implement strategies to improve their effectiveness (Duncan, 2010).

Including these larger themes allows therapists to see that the intentions of PCOMS go well beyond management or funder’s cost or efficiency objectives—client based outcome feedback is about client privilege and benefit, and helping therapists get better at what they do. In addition, it is also critical that therapists know that management only intends to use data to improve the quality of care that clients receive, that there will be no punitive use of the data in any way, shape, or form. Given that most therapists improve their outcomes with feedback ( 9 of 10 therapists improved in the Anker et al. trial), a positive, non-competitive approach goes a long way to assuage therapists’ fears.

3. We go to the doctor and expect that our blood pressure will be taken, we will be weighed, and our heart rate monitored. But when we go see a behavioral health professional there is no such standard measures. Is this patient preference? Clinician Preference? Both?
It is definitely not client preference. Consumers want to be involved in their own care. However, they don’t want to do meaningless paperwork that takes away from their time with the therapist. Consumer involvement in all decisions that affect care is the foundation of the PCOMS intervention, including persons not of the dominant culture as well as the traditionally disenfranchised. We have found that when people understand the purpose of the measures (keeping their voice central and making sure they are getting what they want), refusal rates are about one in a hundred. This is far more of an issue for therapists as discussed above.

4. Where do you see the field going in the near term?
Given that there are now nine RCTs supporting it, the time for client-based outcome feedback seems to have arrived (Lambert, 2010). I think that within 5 years, it will be standard practice. My optimism comes from several recent events. For example, the American Psychological Association (APA) Presidential Task Force (hereafter Task Force) on Evidence-Based Practice in Psychology (EBPP) defined EBPP 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). Two parts of this definition draw attention to client feedback and to tailoring services to the individual client. First, regarding clinical expertise, the Task Force submitted:
Clinical expertise also entails the monitoring of patient progress… If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate. (APA, 2006, p. 276-277)

And second, “in the context of patient characteristics, culture, and preferences,” emphasizes what the client brings to the therapeutic stage as well as the acceptability of any intervention to the client’s expectations. The Task Force 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).
Outcome, in other words, is not guaranteed regardless of evidentiary support of a given technique or the expertise of the therapist. Client-based outcome feedback must become routine.

Further support comes from APA’s Division 29 Task Force on Empirically Supported Relationships who advised practitioners “…to routinely monitor patients’ responses to the therapy relationship and ongoing treatment. Such monitoring leads to increased opportunities to repair alliance ruptures, to improve the relationship, and to avoid premature termination” (Ackerman et al., 2001, p. 496). Finally, two other recent endorsements of outcome management by APA have emerged. First the APA Commission on Accreditation (2011) states that students and interns: “Be provided with supervised experience in collecting quantitative outcome data on the psychological services they provide…”(2011, C-24). And second, APA recently created a new outcome measurement database to encourage practitioners to select outcome measures for practice ((http://practiceoutcomes.apa.org).

So change is on the horizon.

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Multicultural proficency and social justice are integral to the Heart and Soul of Change Project and we see the use of the ORS and SRS as ways of building cultural proficiency and operationalizing social justice. Our resident social justice expert, Dr. Jacqueline Sparks, is conducing a webinar on this topic on February 24th at noon Central Time. Here is the description:

Multicultural Proficiency, Social Justice, and Partnering with Clients: Transforming Relationships of Power though CDOI
Mental health disciplines recognize the role of clients’ culture in the provision of effective and socially just services, and diversity training is prominent in most agencies and professional programs. Despite this, there is little evidence that this emphasis has led to more effective or socially just clinical work. This webinar suggests that mental health theories, policies, paperwork, and procedures continue to reproduce relationships of power that diminish client self-determination, the heart of socially just mental health practice. CDOI redefines whose voice counts and ensures that clients who differ from their counselors and represent non-dominant social groups can direct services that best fit their preferences.
This webinar will:
1. Examine the effects of inequity built into everyday mental health practices
2. Discuss emerging research in social justice in mental health
3. Present a new framework for socially just practice in mental health
4. Discuss tools for assessing social justice in participants’ own or agency practice and for devising strategies for instituting CDOI at all levels to create more equitable and effective therapeutic partnerships.

You must be a CDOI member to participant (click below)

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The Norwegian-American research team (Jesse Owen, Morten Anker, Jacqueline Sparks and Barry Duncan) has scored again, our fourth article based on the massive Norway Couple Feedback Study. Our article, “Initial Relationship Goal and Couple Therapy Outcomes at Post and Six Month Follow Up” has been accepted for publication in the Journal of Family Psychology. This study shows the benefits of knowing what couples want to accomplish in therapy at the outset as well as how couple therapy can help folks regardless of their goals of wanting to improve the relationship or get out of it. It is based on the scale developed by Morten Anker as well as his experience with couples wanting a variety of different things from therapy. Most if not all research in couple therapy deals with couples who desire to improve their relationship but that only covers a portion of the couples we see in real life. This study addresses that reality. It confirms the common sense notion that couples wanting to improve their relationship get better outcomes and are more likely to be together at follow up than couples in which one or both individuals are seeking clarification regarding the viability of the relationship. Moreover, it also demonstrates that couple therapy can benefit clients regardless of their initial goal. We conclude that therapist awareness of each individual’s relationship goal prior to couple therapy could enhance outcomes and treatment tailored according to initial goals could set the stage for positive outcomes however defined.

Jesse Owen, who is now a Project Leader, is doing a webinar via the member site on January 27 about these issues (Become a CDOI Member to participate):

The Couple Therapy that Nobody Talks About: Ambivalence, Commitment, and Change
This webinar discusses couple therapy in which at least one partner is ambivalent about the viability of the relationship. Commitment is vital for couples to successfully develop a secure emotional base and maintain a healthy relationship. When commitment wavers it affects nearly all aspects of the relationship, such as communication, couple identity, willingness to sacrifice, as well as respect, trust, and safety. Treating couples with wavering commitment is rarely discussed in either the theoretical or empirical literature. This webinar covers: (a) cutting-edge research on the importance of assessing couples’ initial relationship goals as a facet of the working alliance; (b) a theoretical framework to understand couples’ commitment; and (c) treatment guidelines for treating couples when at least one partner desires to clarify the viability relationship.

Two other items of interest: A brief video about On Becoming a Better Therapist that I did at APA: http://www.apa.org/pubs/books/interviews/4317217-duncan.aspx

And an interview I did with an old friend from graduate school who hosts a radio show:
http://www.clientdirectedoutcomeinformed.com/media/mp3/Wake_Up_Call_2011-11-20.mp3

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The American Academy of Pediatrics (AAP) recently updated their guidelines for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) to include preschool children (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2654 ). The lowered age limit for treatment in the new AAP guidelines inevitably will increase the use of stimulant medications for this vulnerable age group. The use of these drugs and diagnoses of ADHD continue to rise (http://psychiatryonline.org/cgi/content/abstract/appi.ajp.2011.1103038). The numbers are sure to swell as pediatricians are given the green light to prescribe psychostimulants for very young patients.

Treatment related evidence for the AAP clinical ADHD practice guidelines relied on a recent review prepared by the Agency for Healthcare Research and Quality (AHRQ) (Charach, 2011). This review examined 15 reports representing 11 investigations of the use of psychostimulants by preschoolers and claimed that studies found the drugs to be safe and efficacious. However, the review acknowledges that “the evidence comes primarily from short-term trials lasting days to weeks with small samples” (p. Es-8). When comparing methylphenidate with parent behavior training (PBT), the review concludes that the strength of evidence for use of PBT was high due to number of studies and consistency of results but low for methylphenidate because of only one good-quality study (The Preschool ADHD Treatment Study, PATS). While PATS found modest differences on endpoint measures between the drug and placebo, only 21% of best-dose methylphenidate achieved defined criterion for remission set for school-age children diagnosed with ADHD. Moreover, 30% of parents spontaneously reported moderate to severe adverse events in all phases of the study, including irritability, repetitive behaviors, tics, and emotional outbursts (Wigal et al., 2006). For those children who remained on medication, annual growth rates were 20.3% less than expected for height and 55.2% for weight (Swanson et al., 2006).

In 2006, the Drug Safety and Risk Management Advisory Committee of the FDA urged stronger warnings on ADHD drugs, citing reports of serious cardiac risks, psychosis or mania, and suicidality for children taking them. A review of past studies on the effect of ADHD drugs on children’s growth found that the drugs suppress both height and weight for the duration of the trials that were studied (Drappatz et al., 2006). Height and weight effects were noted by the AHRQ review. Moreover, the AHRQ review cites that “Evidence that psychostimulant use in childhood improves long-term outcomes was inconclusive” (p. vii). . . [and] the majority of studies examining the long-term safety and efficacy of ADHD drugs are industry-funded and may result in “enhanced representations of efficacy and safety” (p. ES-9). The report concludes: “The increasing use of off-label prescriptions [of ADHD drugs] for very young children is concerning . . . “There is one primary implication from the review . . . the first line intervention for young children [at risk of ADHD] is evidence-based PBT” (p. 171).

Based on their own investigation, opening the floodgates for ADHD medications for children under the age of 6 is not justified. In light of current evidence, the International Society for Ethical Psychology and Psychiatry (ISEPP) strongly opposes the new AAP Guidelines and urges the AAP to reconsider the implications for lowering the age for which ADHD drugs may be recommended. The ISEPP further urges the AAP to retract their new guidelines until such evidence surfaces that ADHD drugs provide an acceptable risk relative to their benefit for children under the age of 6.

For references, see full position paper at: http://heartandsoulofchange.com/resources/psychiatric-drugs/

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Speaking of research, there are several research projects that are in process: an RCT with returning veterans with PTSD related problems and substance abuse concerns is in the writing phase; an RCT with children with behavioral problems in the schools is in its second year of data collection; a comparison trial of residential treatment services with and without CDOI for clients with the “SMI” moniker is underway; an RCT with prescribers of psychotropic meds is in the planning stages; and a component study addressing why the feedback intervention works is also in the planning stages. I’ll keep you informed of the progress.

Along the lines of Sami Timimi’s “No More Psychiatric Labels” campaign to abolish diagnostic systems like ICD and DSM (Check it out at http://www.criticalpsychiatry.net/?p=527  Support the campaign at http://www.causes.com/causes/615071-no-more-psychiatric-labels/about), another project is underway that calls attention to the many pitfalls of the psychiatric diagnosis. I just signed their petition. Check it out: “Open Letter to the DSM-5″
http://www.ipetitions.com/petition/dsm5/?utm_medium=email&utm_source=system&utm_campaign=Send%2Bto%2BFriend

I really think this is an important cause, extremely well articulated, and I’d like to encourage you to add your signature, too. It’s free and takes just a few seconds of your time.

And, I want to call your attention to the Training of Trainers Conference in West Palm Beach, Florida from January 30 to February 3, 2012. There are still a few spots left so don’t miss out on this intense CDOI/PCOMS immersion as well as the fun and sun. I am convinced that the difference between successful and unsuccessful agency implementation boils down to having someone on site that knows the ins and outs of not only CDOI, but also the nuts and bolts of making it happen on an organizational level. Hope to see you there.

Finally, join me for this month’s webinar on ensuring data integrity and therapist understanding on November 23rd at 1PM Central. Join the member site to watch.

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Join me for a webinar on this article on October 19th at 1PM Central. Join the member site to watch.

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My response: Attention to and/or interpretation of transference/countertransference is no more important, and no less, than any other therapist action derived from theory, model, or technique. All approaches tend to work equally well, a finding referred to as the “dodo verdict.” Moreover, model differences or “specific effects” (those aspects unique to a given approach) account for a small amount of the variance of change with an effect size (ES) of only .2. Putting this into perspective, a meta-analysis of the client’s perception of empathy found an ES of .32. This is not meant to denigrate transference/countertransference or any other model-based idea or technique but rather to suggest what Saul Rosenzweig concluded 75 years ago–given that all approaches appear to work about the same, there must be common factors that account for therapeutic change.

One such factor (originating from psychodynamic thinking) holds far more sway over outcome–the therapeutic alliance. There are over 1000 studies that support the association between a strong alliance and positive outcome. The alliance accounts for five to seven times the amount of variance attributed to model and technique. It transcends any specific therapist behavior and is a property of all. It functions to engage the client in purposive work and includes both a relational connection and an agreement about the goals and tasks of therapy. Importantly, the alliance is dependent on the delivery of some particular treatment—a framework for understanding and solving the problem. Technique–whether interpreting transference or challenging dysfunctional thoughts–is the alliance in action.

While there is no differential efficacy among approaches on aggregate, there is with the client in your office now. The question is: does it resonate or not? Does its application help or hinder the alliance? Does the client engage in the work and make meaningful changes when you attend to or make transference/countertransference interpretations?

The only way to answer this question is to risk our romance with our theories and secure client-based feedback about outcome and the alliance–a process now shown in nine RCTs to significantly improve outcomes regardless of the treatment administered. For example, the largest trial of couples therapy ever done found that clients who gave their therapists feedback about the outcome and alliance on two brief, four-item forms reached clinically significant change nearly four times more than non-feedback couples did .

The constructs of transference/countertransference have a storied history steeped in the tradition of psychoanalytic thinking. Approaches that hold these ideas dear are just as effective as those that don’t. Regardless of model, however, most therapists can increase their effectiveness substantially through identification of those clients who are not responding and addressing the lack of change in a way that keeps clients engaged and forges new directions. The evidence calls for a “new therapist,” a more sophisticated clinician who chooses from a variety of orientations and methods to best fit client preferences and cultural values based on feedback about the benefit and fit of services.

The Training of Trainers event is coming up quick.  Learn how to train others in CDOI and PCOMS! Escape the cold this winter and attend the Training of Trainers Conference in sunny Florida, January 30-February 3.

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