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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nora Bateson just completed a documentary film about her father which is not only a beautiful honoring of a father by a devoted daughter, an invaluable account of his impact on many fields, but also a magnificent statement of the interconnectedness of all living things—all embedded in a finely crafted cinematic experience. Nora is a truly gifted speaker and filmmaker, as well as an articulate spokesperson for systemic ideas. She was also was full of life and had a sparkling sense of humor. Check out the film at: http://www.anecologyofmind.com/Home_Page.php

This all came about via my association with the Korzybski Institute (a largely solution focused group with a decided existential twist called the Bruges model) which trains many therapists across Europe but mainly in the Netherlands, Switzerland, and Belgium. A fascinating man, Luc Isabaert, is the director. Luc is a wise and very knowledgeable person about almost everything from Bateson to Belgium Beer (which I capitalize because it is a national treasure)! I am now a trainer for Luc and Korzybski which led to my invitation to this “think tank” session following my kick off training course in Amsterdam which will continue in Bruges and other training sites in May. The theme of the think tank was my old friend, the therapeutic alliance, and the participants ranged from anthropologists, logicians, and organizational consultants to psychiatrists and family therapists. The discussion was fascinating although it was a bit outside of the pragmatic world in which I live and therefore a bit more academic at times than my taste. It brought back make many memories for me because my dissertation was a theoretical one (an option in my program) about systems theory and paradox. I had not thought about these ideas for some time and it was particularly fun to see how they still influence my thinking. And of course, the participants were brilliant and interesting so I spent much of time marveling at it all. And Bruges is absolutely unbelievable, a very well preserved 14th century crown jewel of Belgium. Check out the Institute at: http://www.korzybski.com/index.php?lang=en

Here is my presentation at the think tank about the alliance:

While I often don’t remember where I leave my glasses, I still vividly recall my first client, Tina. A long time ago in a galaxy far way, I was in my initial clinical placement in graduate school at the Dayton Mental Health and Developmental Center, a euphemism for the state hospital. Tina was like a lot of the clients: young, poor, disenfranchised, heavily medicated, and on the merry-go-round of hospitalizations—and, at the ripe old age of 22, a “chronic schizophrenic.”

I gathered up the battery of tests I was attempting to gain competence with, and was on my merry but nervous way to the assessment office, a stark, run-down room in a long past its prime, barrack-style building that reeked of cleaning fluids over-used to cover up some other worse smell, the institutional stench. But on the way I couldn’t help but notice all the looks I was getting—a smirk from an orderly, a wink from a nurse, and funny looking smiles from nearly everyone else. My curiosity piqued, I was just about to ask what was going on when the chief psychologist, a kindly old guy, put his hand on my shoulder and said, “Barry, you might want to leave the door open.” And I did.

I greeted Tina, a young, extremely pale woman with short brown, cropped hair, who might have looked a bit like Mia Farrow in the Rosemary’s Baby era had Tina lived in friendlier circumstances, and introduced myself in my most professional voice. And before I could sit down and open up my test kit, Tina started to take off her clothes, mumbling something indiscernible. I just stared in disbelief. Tina was undaunted by my dismay and quickly was down to her bra and underwear when I finally broke my silence and said, “Tina, what are you doing? Tina responded not with words but with actions, removing her bra like it had suddenly become made of wool and very uncomfortable. So there we were, a graduate student, speechless, in his first professional encounter, and a client sitting nearly naked, mumbling now quite loudly but still nothing I could understand, and contemplating whether to stand up to take her underwear off or simply continue her mission while sitting.

In desperation, I pleaded, “Tina, would you please do me a big favor? She looked at me for the first time, and said, “What?” I replied, “I would really be grateful if you could put your clothes back on and help me get through this assessment. I’ve done them before, but never with a client, and I am kinda freaked out about it.” Tina whispered, “Sure,” and put her clothes back on. And although Tina struggled with the testing and clearly was not enjoying herself, she completed it. I was so genuinely appreciate of Tina’s help that I told her she really pulled me through my first real assessment. She smiled proudly, and ultimately smiled at me every time she saw me from then on.

So Tina started my psychotherapy journey and offered up my first lessons for consideration: authenticity matters and when in doubt or in need of help, ask the client. Those lessons have served me well.

On Becoming demonstrates how systematic client feedback provides the means for clients to teach you how to do good work. It embodies the lessons I learned from Tina, providing for a transparent interpersonal process that solicits the clients help in ensuring a positive outcome.

Please join me this July 22 at 6PM Central for a free webinar discussion of my book. Each month will cover a different chapter. I’ll start our discussion with a 15 minute overview and then I’ll turn it over to you for your questions, comments, and reflections. It should be fun. For those of you who can’t attend live, I’ll record the sessions and post them on the website so you can access the discussions at your leisure. In addition, right after the webinar, I’ll be hosting a two-hour discussion about each chapter of the book on the heroicagencies list .

July 22: 6PM Central to 7:30 It’s free! Every month a free webinar!

Reserve your Webinar seat now at:
https://www2.gotomeeting.com/register/863269466

Drawing on many years of clinical experience and research on evidence-based practice, Duncan argues with conviction and humor that systematically monitoring client outcomes is advantageous to therapists as well as to clients. He offers lessons learned about clients being the best teachers and guidelines for what works in therapy. The guide includes a foreword by Michael J. Lambert, other pearls of wisdom, findings of the Norway Feedback Project, excerpts of therapy sessions, and information on career development tracking software (ASIST, MyOutcomes). –Reference & Research Book News (May 2010)

This will be a three-pronged effort to disseminate the ideas in the book, two of which are free. First, for those who subscribe to CDOI Members (join here for just $120 a year), beginning July 22 at noon Central, I will conduct monthly webinars on each of the seven chapters of the book, adding to the already over $400 of training materials. And stay tuned: Client videos are coming soon to CDOI Members so you will be able to learn CDOI by watching me with actual clients.

And now for the free stuff: Have you ever wanted to ask a question or engage in a conversation with an author when you were reading a book? I know I have. Starting also on July 22 at 6PM Central, I will offer a free monthly webinar discussion of my book. Each month will cover a different chapter. I’ll start our discussion with a 15 minute overview and then I’ll turn it over to you for your questions, comments, and reflections. It should be fun. For those of you who can’t attend live, I’ll record the sessions and post them on the website so you can access the discussions at your leisure. In addition, right after the webinar, I’ll be hosting a two-hour discussion about each chapter of the book on the heroicagencies list (join now). I hope you can join me. I am anxious to hear your impressions and questions about the book.

Here is the free webinar announcement:

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

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

Join us for a Webinar on July 22: 6PM Central to 7:30 It’s free! Every month a free webinar!

Space is limited.
Reserve your Webinar seat now at:
https://www2.gotomeeting.com/register/863269466

Hope you join me!

Newsweek was one of the media outlets that enthusiastically supported the study’s claims. Their article, “Trouble in a Black Box” was written by Tony Dokoupil.

We sent an email to the author and the editor of Newsweek pointing out the problems with the article. The problem was that an examination of the study revealed that the “parallel” development was not parallel at all. A graph in the study clearly demonstrated that the precipitous drop in prescriptions occurred after the increase in suicides. As you read this exchange, keep in mind that everything we pointed out was eventually acknowledged by both the New York Times and The Boston Globe – but not Newsweek.

Dear Editor:
Please find below our letter in response to the article, “Trouble in a Black Box.” Our examination of the study forming the basis for the article revealed a glaring inaccuracy–the study’s results do not match the findings reported in the Newsweek article. Given that very few individuals read or understand research, we believe it important for Newsweek readers to be aware of this discrepancy to evaluate the necessity of the Black Box warning:

Tony Dokoupil’s Trouble in a ‘Black Box’ (July 16) importantly addresses the risks and benefits of prescribing antidepressants to children. However, the referenced study is far from “compelling” evidence for removing the FDA Black Box warning and such an interpretation of its findings is misleading. An inspection of this industry funded study reveals that the precipitous drop in SSRI prescriptions did not occur, as reported, from 2003 to 2005 but rather from February to October of 2005 (over 85% of the drop in the last 6 months of the reported time). The so-called “parallel development” of increased suicides occurred between 2003 and 2004—and therefore had no relationship to the drop in prescription rates reported in this study. Given that the decrease in prescription rates and increase in suicides occurred in different time periods, it begs the question of how such unsubstantiated statements could be made by the experts cited in the article.

Only 3 of 15 clinical trials have shown antidepressants to be superior to a sugar pill on primary measures. Children and parents in those 15 studies reported no advantage of antidepressants over a sugar pill. Data from the FDA and its British counterpart demonstrate that children and adolescents taking antidepressants are twice as likely to experience suicide-related events. Given the meager results and increased risk for suicide-related events (as well as other serious adverse events), antidepressants are not a good first choice for youth struggling with depression—a conclusion reached after an extensive risk/benefit analysis conducted by the American Psychological Association’s Work Group on Psychotropic Medication

Dear Dr. Duncan:
Thank you for responding to my recent story, “Trouble in a Black Box.” In answer to your concerns, I writing to let you that the important “parallel development” we had in mind was that child and adolescent use of antidepressants dropped (for the first time since coming on the market) while suicides rose significantly for the first time since the late 1970s. The fact that antidepressant use dropped most steeply in 2005, the year for which suicide data is still forthcoming, may merely foreshadow trouble–which is why the FDA is concerned. “The evidence is very compelling,” they say.
Tony Dokoupil

Dear Mr. Dokoupil:
Thanks for your note. I understand the proposed relationship between the increase in suicides and decrease in prescriptions that your article and the cited experts were asserting. But the evidence for such a relationship is far from “compelling” when the two developments occurred over different time periods. Your article and the cited experts gave the impression that the “parallel development,” as the word “parallel” suggests, occurred during the same period and therefore were related to one another. This was quite misleading given that an inspection of the study and its graphs revealed something quite different. Had you only commented that it could be a foreshadowing, and offered other explanations, then the article would have not so misrepresented the data. I would appreciate your clarification for Newsweek readers or that my letter be published.

Dear Ms. Lichtschein and Mr. Dokoupil:
I would greatly appreciate knowing your decision regarding our letter. It is of course your perrogative to print or not print any letter you receive. In this case, however, we believe it is critically important for you to get the facts straight because of the unfortunate misrepresentation of the data reported in your article. It is particularly troubling given the bold and even outrageous comments made by the cited experts which, at times, bordered on hysteria and fear mongering, far removed from an objective interpretation of the facts. Perhaps an interesting story would address how the drug company affiliated researchers responded to the findings as a “parallel development” while understanding full well that the precipitous drop in their study occurred after the increase in suicides.

Dear Dr. Duncan,
We appreciate your concerns, but don’t have plans to run your letter. We feel that the story adequately expresses the available data, which concerns the simultaneous snapping of two 15 year trends. The fact that the sharpest drop in antidepressant use occurs in the year for which suicide data is still forthcoming is significant, but more significant in this context is the reversal of a steep, longstanding trend toward increased SSRI use. We also sought comment from experts with interests on all sides of the issue.
Tony Dokoupil

Dear Mr. Dokoupil:
Thank you for your response. Just for the record, you are stating that you will not print our letter because “the story accurately expresses the available data.” We have, in fact, shown that, based on data from the cited study, it does not. The “simultaneous snapping” of the two trends is clearly neither simultaneous nor “parallel” as your story and letter depict. Nor is there enough available evidence to make any definitive statement about youth suicide trends for the time frame mentioned. Perhaps you “sought” consultation from experts on both sides. However, you did not publish both sides. Nowhere in the story are there opposing points of view or other possible interpretations for any trends the existing data might foreshadow. We must assume that, based on your refusal to publish a valid and important counterpoint, it is your intention to keep counter voices from your readers. Not only does this do a disservice to your readers, it walks a perilous line. It reflects how a major media source can, through biased reporting, create unjustified fear and potentially influence the repeal of a warning label implemented, after extensive scientific debate, to protect children. It is our belief that any observer of this process may likely view it as we do—representative of neither balanced nor ethical journalism, especially as it involves a life-and-death issue impacting our nation’s youth.

Thus, while The New York Times and The Boston Globe addressed the problems Newsweek never did. Strike one.

Particularly egregious were the comments in the Newsweek article by Robert Vuluck: “You may induce two suicides by treatment, but by stopping treatment you’re going to lose dozens to hundreds of kids. You’re losing more than you’re saving. That’s the calculus,’ says Dr. Robert Valuck, of the University of Colorado Health Sciences Center.”

While sloppy journalism and lack of fact checking is expected from the media, the bold and even outrageous comments that Valuck made went well beyond just an unfortunate misrepresentation of the data. His comments bordered on hysteria and fear mongering, far removed from an objective interpretation of the facts and offered a conclusion from the data that he must have known, as a study co-author, to be false. This is a serious ethical violation because it created unjustified fear and could potentially influence the repeal of a warning label implemented, after extensive scientific debate, to protect children. This was neither balanced nor ethical science especially as it involves a life-and-death issue impacting our nation’s youth.

Researchers, especially those funded by corporate interests have to be held accountable. We tried to hold him accountable but the University of Colorado Committee on Research Ethics (CRE), specifically, John E. Repine, M.D. who informed us that the CRE did not find sufficient evidence to warrant an inquiry. Strike two.

That’s the past. But these things happen all the time. Case in point. Consider an article just out in the New Yorker:

http://www.newyorker.com/arts/critics/atlarge/2010/03/01/100301crat_atlarge_menand  

It is a review of two new books about antidepressants. It has many redeeming qualities in that it acknowledges the problems with diagnosis and the research suggesting that antidepressants are no more effective than placebo. But it’s all downhill after that, and begins making a not so hidden argument for antidepressants. It purports to do a pro/con analysis of the drugs and psychotherapy but makes two incredulous omissions. One is that it doesn’t discuss, at all, the adverse effects of antidepressants; and two, it fails to mention long term comparisons between psychotherapy and medication. Finally the article cites (and significantly misrepresents) the STAR*D study to support antidepressants, and to refute the claim that SSRIs are no better than placebo.

After I read it, there was no turning back. I had to respond. Do any of you know a cure for that? I included Jackie and my analysis of the STAR*D study from the new Heart and Soul of Change. Given it calls into question their fact checking, I doubt it will be published. Strike three, Barry, yer out!

Here it is:
In the entertaining review, “Head Case,” Menand effectively covered the controversy surrounding psychiatric drugs. Two important issues, however, relevant to assessing the risks and benefits of psychiatric medication were omitted: the significant side effect profile of antidepressants and the poor performance of antidepressants in the long haul (especially as compared with psychotherapy). The STAR*D study illustrates. In the STAR*D, the average remission rate based on the primary outcome measure was 28% and 25% on the first two levels, and 14% and 13% on the last two. At Level 1, 28% experienced moderate to intolerable side effects. At Level 2 (participants augmented or switched), 51% experienced side effects ranging from moderate to intolerable. For all levels, 24% exited due to drug intolerability. Data from the 12-month follow-up of those who either remitted or responded indicated a relapse rate of 58%. Menand’s review omits the significant number of STAR*D drop-outs and claims that a 67% effectiveness rate after all levels. This figure was apparently derived by cumulatively adding percentage rates across levels, a practice statistically meaningless and certainly misleading. Since the rates of effectiveness are calculated from the numbers of participants in each level, average, not cumulative percentages correctly reflect overall improvement. For example, in the first two levels, out of a total of 4,168 participants, 1114 achieved remission, a 27% effectiveness rate, not the 56% rate reported by Menand. When drug studies are reported, original sources must be examined to insure that risks and long term follow up are considered.

Hope to see you soon in New Orleans!

1. Do you have any tips on how to motivate resistant clients, i.e., non-compliant, court-ordered, or mandated clients to positive change? Clients may not share our motivations, but they certainly hold strong motivations of their own. Research has now established that the critical process-outcome link in successful therapy is the quality of the client’s participation. Clients who collaborate in therapy, are engaged with the therapist, and involve themselves with a receptive and open mind will likely profit. Owing to the importance of clients’ positive involvement for outcome, their motivation—not only just for being in therapy, but also for achieving their own goals—has to be understood, respected, and actively incorporated into the treatment. To do less or to impose agendas motivated by theoretical prerogatives, personal bias, and perhaps some sense of what would be good for the client, invites “resistance.”What we come to call resistance may sometimes reflect the client’s attempt to salvage a small portion of self-respect.

Important findings regarding court-ordered or mandated clients emerged from Project Match, the largest study of substance abuse ever done. First, there was no difference in outcome between mandated and non-mandated clients; and second, the only predictor of outcome, whether the client was voluntary or involuntary, was the therapeutic alliance. Whether clients are “resistant” or mandated, job one is the therapeutic alliance. It’s not always easy. But you didn’t think that “therapeutic work” business only applied to clients—did you?

2. As students, we often get overwhelmed with a plethora of theoretical models and techniques. How important is technique delivery in being an effective therapist who creates positive results in the majority of our clients? Sometimes our altruistic desire to be helpful hoodwinks us into believing that if we were just smart enough or trained correctly, clients would not remain inured to our best efforts—if we found the Holy Grail, that special model or technique, we could once and for all defeat the psychic dragons that terrorize clients. Amid explanations and remedies aplenty, therapists courageously continue the search for designer explanations and brand name miracles—disconnected from the power for change that resides in the pairing of two unique persons, the application of strategies that resonate with both, and the impact of a quality partnership.

Don’t get me wrong. There is nothing wrong with learning about models and techniques—in fact, it is a good thing because it allows you to fit more client preferences. But becoming beholden to one is folly as is the belief that any model represents the way that people can be helped. Technique is important but it is only effective to the extent that it engages the client in purposeful work. If it does not pass that fundamental test, it has no value regardless of its evidentiary support. Moreover, a particular technique is only important to the client in your office now if it results in measureable benefit. The proof of the pudding is in the eating.

3. What is the history of the use of outcome measures in psychotherapy and what do you think its future role will ultimately be in managed care? Ken Howard first advocated for the evaluation of client response to treatment during the course of therapy, but feedback pioneer Michael Lambert really brought the idea to fruition. He has conducted six RCTs that have demonstrated significant gains for feedback groups over treatment as usual (TAU) for clients at-risk for a negative outcome. The addition of client feedback alone enabled over two times the amount of at- risk clients to benefit from psychotherapy. Our recent RCT of couple therapy found that feedback clients reached clinically significant change nearly four times more than non-feedback couples.

Collecting data and managing outcomes can allow therapists, agencies, and professional organizations to become “players” at the reimbursement table with managed care. The advantages in effectiveness and efficiency that outcome management brings can be bargaining chips that increase the value of our services. We should support managed care systems that collect data and provide immediate feedback about results so that we can adjust quickly to benefit clients. On the other side, we should oppose data collection for the purpose of provider profiling and incentive practices without feedback. Such policies risk killing the spirit of outcome management—to help as many clients as possible—and turning therapists against measuring outcomes.

4. What changes in thinking and practicing are you hoping that participants walk away with from your trainings? There are two things I would love for folks to walk away with. First is that regardless of one’s preferences regarding theory or technique, outcomes can be improved by paying more attention to the heart and soul of change: Rallying the client and his or her resources to the cause, their participation, is the heart of the work; and proactively securing that tried and true but taken for granted old friend, the therapeutic alliance—the soul of change is the alliance. The second change that I hope for is that folks will give client feedback a shot, not some time, not next month or even next week, but with the next client. Client-based feedback substantially increases the effectiveness and efficiency of services—more than anything in the history of our field. It enhances the benefit of any psychotherapy regardless of the model practiced. Nine of ten therapists in our large RCT improved their outcomes with feedback; in fact a therapist in the lowest tier of effectiveness without feedback became the most effective therapist in the study with feedback.

And two announcements: One is that pdfs of all the Heart and Soul of Change Conference presentations are now available at: http://heartandsoulofchange.com/heart-and-soul-of-change-conference-new-orleans-slide-presentations/

And the next webinar is scheduled: our own Bob Bohanske presenting “Implementing CDOI in Public Agencies: Is it Mission Impossible?”

Prescriptions for antipsychotics for children continue to skyrocket, despite underwhelming evidence. Here is how we wrote about the NIMH funded Treatment of Early Onset Schizophrenia Spectrum Disorders (TEOSS) (Sikich et al., 2008) in our recent chapter in the Heart and Soul of Change, 2nd Edition (Sparks, Duncan, Cohen, & Antonuccio, 2010):

“Described as a landmark trial (McClellan et al., 2007), TEOSS sought to examine the efficacy, tolerability, and safety of two second generation antipsychotics (SGAs; Risperdal and Zyprexa) for youths diagnosed with early-onset schizophrenia spectrum disorder and to compare these to a first generation antipsychotic FGA (molindone or Moban). Fewer than 50% of subjects completed 8 weeks of treatment and response rates were low and not significantly different for all three groups (Sikich et al.). Participants in the study were allowed concomitant use of antidepressants, anticonvulsants, and benzodiazepines, compromising even these disappointing findings. A 17-year old boy committed suicide and an unspecified number of participants were hospitalized due to suicidality or worsening psychosis. These events are particularly disturbing in light of the fact that youths considered at risk for suicide were excluded from the study. Weight gain was deemed serious enough to warrant suspension of the Zyprexa arm (McClellan et al.).”

It gets better or should I say worse? Follow up, available on line and soon to be published in the June issue of Journal of the American Academy of Child & Adolescent Psychiatry (see the abstract at http://www.jaacap.com/article/S0890-8567(10)00294-7/abstract, revealed that only14 of the 116 youth (12%) responded to the medication and stayed on it for one year. That’s right, you read it correctly–12%! Recall that in the famous adult trial of antipsychotics (the CATIE trial) that 74% dropped out. So it is even worse in youth—88% failed to benefit.

So let’s break this down. First, TEOSS was not placebo-controlled. The 116 youth enrolled into the trial were randomized either to a first generation antipsychotic (Moban) or to an atypical antipsychotic or so called second generation antipsychotic (Risperdal and Zyprexa). At the end of eight weeks, the response rate was 50% for those treated with Moban, 46% for Risperdal, and 34% for Zyprexa. Adverse events were “frequent” in all three groups.

Only those youth who “responded” during the initial eight weeks — 54 of the 116 — were entered into the 44-week maintenance study. Forty of the 54 youth dropped out during this period because of “adverse effects” or “inadequate response.” Thus, only 14 of the 116 youth who entered the study responded to the medication and stayed on it for as long as one year—only 12%.

Pharmacotherapy helps some children and adolescents, although apparently not very many. However, the preponderance of empirical research indicates that the risk may not be worth it. While pharmacotherapy involves considerable risk for young people, psychosocial interventions have a strong track record with virtually no adverse associated medical events. APA’s Working Group on Kids and Psychotropics (2006) concluded:

For most of the disorders reviewed herein, there are psychosocial treatments that are solidly grounded in empirical support as stand-alone treatments. Moreover, the preponderance of available evidence indicates that psychosocial treatments are safer than psychoactive medications. Thus, it is our recommendation that in most cases, psychosocial interventions be considered first. (p. 16. Italics added)

As the evidence regarding TEOSS suggests, the automatic prescription of antipsychotics for sure, but with any psychotropic, is unwarranted. Where children are concerned, the stakes are higher. They are, essentially, mandated clients—most do not have a voice to say no to treatments or devise their own, and depend on adults to safeguard their wellbeing (Sparks & Duncan, 2008). If you are seeing kids taking antipsychotics, you are on very firm ground to raise concerns and ensure the treatment is fitting client preferences.

Read more about psychiatric drugs and the evidence at http://heartandsoulofchange.com/resources/psychiatric-drugs/

And many of you know that I did a radio show on Voice America about this same issue with Marcia Barbacki and David Cohen (many episodes available at http://heartandsoulofchange.com/resources/audio-presentations/ ). Marcia is the most persistent and selfless person I know. She works tirelessly at her own expense to bring this controversial topic to mainstream awareness and her efforts over the past three years have focused on enlisting the Catholic Church to help stem the tide of rising prescriptions, especially to kids given they have little voice in such decisions. I was intrigued and inspired by the idea that the Church and her vessels could counter the forces of corporate power and greed. Few institutions or even governmental entities seem to be able to stand up to economic tsunami of the pharmaceuticals…over 40 billion in sales last year and more spent on marketing than on research and development; and there is a pharmaceutical lobbyist assigned to every member of congress. Remember that good marketing, and unlimited lobbying, can overcome bad data every single day of week. Knowing that, I couldn’t help but be smitten by the idea that if the Church could be persuaded that the evidence does not support the prescription rates especially with children, considering the risks, then, through all the channels available—religious communities, churches, and schools—they might promote a cautionary, no first line use stance , and call for each professional to look at the evidence him or herself as well as a more defined separation between the pharmaceutical industry and research/education. For a great article about the negative effects of blurring this distinction as well as recommendations to fix the influence of drug companies on research and education, see Marcia Angell’s excellent article at: http://bostonreview.net/BR35.3/angell.php. This is not a wide eyed anti drug zealot but rather a former editor of the New England Journal of Medicine. I hope that this article might convince you that we are not just conspiracy theorists!

Marcia Barbacki and I recently did a presentation in Lourdes, France—a place that is inspiring on many levels—to an international group of Catholic physicians, nurses, pharmacists, and other health care professionals. Check out this presentation available in PowerPoint for your free download as well as the narrative summary at a new page of articles about psychotropics: http://heartandsoulofchange.com/resources/psychiatric-drugs/. The video from the presentation will be available soon. It will at the least be entertaining because I am wearing a suit and look like a fish out of water or perhaps like Gomer Pyle in his Sunday best. Golly! Marcia’s efforts and the presentation paid off. I am presenting at the Vatican’s annual conference in November. This could lead to an international conference on this important topic. Keep your fingers crossed.

And speaking of kids and drugs, Jacqueline just sent me this music video on ADHD:

And now for something completely different: I also wanted to remind you about the CDOI Directory. The benefits of listing will only increase over time as it becomes more known. Traffic to the site is increasing and will continue as other things develop including upcoming press releases about the alliance article as well as Networker and Psychotherapy in Australia articles. Besides allowing others to find you and know that you aspire to CDOI ideas and practices, it will allow you to network with folks holding similar values about practice, perhaps allowing you to find a local community. It can also provide additional exposure of your practice and let potential funders, interns, volunteers, etc, know of you and your interests. Over time, I hope to let funders know of our list and the benefits that members can offer because of their attention to client benefit and the alliance. And Rebecca just added another feature. You can download the CDOI Registered Provider icon from your listing and place it on your website to inform your visitors of your membership in the directory and what it means.

I am hoping for 100 members by the time of the Heart and Soul of Change Conference so I can show it to folks. I would appreciate your consideration. And while you are considering that, consider coming to the conference!

There’s a lot of talk about what makes some therapists more effective than others, and a lot of claims unsubstantiated by research. But what really makes a difference in outcome is that tried and true but taken granted old friend, the alliance. The most definitive thing we know about what makes some therapists better than others is their ability to secure a good alliance across a variety of client presentations and personalities. This finding was recently confirmed by a sophisticated analysis by Scott Baldwin and colleagues in perhaps the premier psychotherapy research publication, JCCP. It also dispelled common folklore by demonstrating that good alliances were more of a function of what therapists brought to the table than clients; i.e., therapists adept at alliances were able to transcend type of client while other less effective therapists were not. Further, and simply put, the alliance accounts for five to seven times the amount of variance of outcome as model and technique. And, according to the bible of psychotherapy outcome research (Garfield and Bergin’s Handbook of Psychotherapy and Behavior Change, the Orlinsky, Rønnestad, and Willutzki chapter) there are over 1000 process-outcome findings that support the association between a strong alliance and positive outcome.

Despite this, however, naysayers (read model maniacs, I mean proponents) will dismiss the alliance by saying the research is only correlational. Even more damning, they say, is that we don’t know which comes first, client experience of a strong alliance or client report of change or benefit—the classic chicken or the egg question. Enter our just accepted alliance study that involved a total sample of 500 clients. The alliance significantly predicted outcome over and above early change, demonstrating that the alliance is not merely an artifact of client improvement but rather a force to be reckoned with in and of itself. Don’t let anyone tell you that the alliance is anything less than it is—the single greatest impact we can have on client change. We can continually improve our ability to form strong alliances with a broader range of clients, and thereby improve our effectiveness. Don’t leave it to change. Monitor with your clients.

A new feature just added to the website: The Heart and Soul of Change Project Mailing List. This list won’t cover you up in email or leave you hurling harsh language at me—I promise. You will only receive 4-6 updates per year about the latest training opportunities and Project happenings.  Subscribe/unsubscribe or change your profile.

Finally, the next webinar is scheduled:

Have you ever wondered how to present client directed outcome informed (CDOI) ideas and practices to a general rather than professional audience? Wonder no longer, because that is what I did in my self help book, What’s Right With You and that’s what this webinar will do:

We live in a world pervaded by the unspoken attitude that we are all basically flawed, broken, incomplete, scarred or sick: we’re labeled as dysfunctional, codependent, depressed, you name it. Contrary to popular perception and drug company ad campaigns, fifty years of research shows that positive change does not primarily emerge from examining the disorders, diseases, or dysfunctions—all the stuff that’s wrong with us—that allegedly plague the masses. Change, in truth, comes from what’s right with the people attempting it—their strengths, resources, ideas, and relational support—not the labels they are branded with, the special expertise of doctors or the magic methods or potions they peddle.

In this webinar Barry translates CDOI into a six step plan, as detailed in his self help book, What’s Right With You.

Title: What’s Right With You by Barry Duncan
Date: Friday, May 28, 2010
Time: 12:00 PM – 1:00 PM CDT

Join the CDOI Members or wait until this webinar is posted on the bookstore.