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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On another note, a study (a collaboration of UK and UCA by students of Jeff Reese and Art Gillaspy—see all the names on the below poster presentation slide) has just been completed about the social desirability and the SRS. Clients were randomized to three feedback conditions: (1) Immediate Feedback (I) – SRS completed in presence of therapist and the results discussed immediately afterward; (2) Next Session Feedback (NS) – SRS completed alone and results discussed next session; or (3) No Feedback (NF) – SRS completed alone and results not available to therapist. No statistically significant differences in SRS scores across the feedback conditions were found, indicating that alliance scores are not inflated due to the presence of a therapist or knowing that the scores will be observed by the therapist. Additionally, the analysis showed that SRS scores were not correlated with a measure of social desirability but demonstrated evidence of concurrent validity with an established alliance measure. Here is a summary of the study, a poster presentation at APA.

This study is important because it helps put to rest the argument that clients only respond in socially appropriate ways on the SRS or are unduly influenced (demand characteristics) by the therapist’s presence. This study offers yet another way to counter nay-sayers with data. With the ORS, research in general shows that clients tend not to misrepresent distress but more specifically, in the Norway feedback Trial, the 6 month follow up showed a maintenance of the feedback effect—client ratings remained consistent even though the measures were mailed and no therapist was present when clients filled them out.

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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1. Attention to the common factors of change and the evidence demonstrating that most of therapist variability is accounted for by alliance abilities: PCOMS, the feedback intervention, is viewed as an interconnected part of the healing factors of psychotherapeutic intervention and the tie that binds the other factors 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 therapist-client fit and client participation, and is itself a core feature of therapeutic change. The natural fit between the common factors research literature and PCOMS is integral to the implementation process of the Heart and Soul of Change Project.

2. A focus on the clinical nuances of using PCOMS as detailed in On Becoming a Better Therapist, addressing how to get the maximum feedback effect. Although the now 300,000 administrations of the measures and all the information that has yielded in terms of the psychometrics of the measures, trajectories, algorithms, etc., has been invaluable, PCOMS remains a clinical intervention embedded in the complex interpersonal process we call psychotherapy. The Heart and Soul of Change Project keeps this in mind and therefore appeals to the clinician in ways the numbers never can.

3. Similarly, a focus on therapist development and how therapists naturally want to get better over the course of their careers 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 outcome 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 of us got into this business in the first place: to make a difference in the lives of those we serve. Research demonstrates that nearly all therapists want to continue to improve over their careers and harnessing this motivation is part and parcel of how the Heart and Soul of Change Project implements PCOMS.

4. Attention to Multiculturalism and Social Justice is a key element of PCOMS (and of the Training of Trainers Conference). Client privilege and voice form the foundation of the PCOMS intervention. Privileging the client via PCOMS levels the counseling process by inviting collaborative decision making, honoring client diversity with multiple language availability, valuing local cultural and contextual knowledge, and amplifying the voice of the disenfranchised. We see PCOMS as a way of building cultural proficiency.

5. Attention to the concept of “Recovery” as defined by the National Consensus Statement is core to PCOMS and a natural fit—a journey best directed by the individual in the context of a true partnership providing both hope and accountability. PCOMS offers a vital way to operationalize the Consensus Statement into clinical practice.

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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I am pleased to announce that Luc Isebaert will join The Heart and Soul of Change Project as a Project Leader. I don’t know if you have seen the Dos Equis commercials about the “most interesting man in the world” but since meeting Luc, I beg to differ. Luc is truly a renaissance man, and a walking encyclopedia of art, music, wine, beer (his family ran a brewery and if you know anything about Belgium, you know that beer is a national treasure), history, and of course psychotherapy. Luc is also a gourmet chef and I had an amazing dinner at his home and his partner Sophie (a concert pianist who played for us over a glass of incredible Riesling wine on a piano that Franz Liszt played at the Paris World Fair in 1878). Luc and I share a common heritage in Ericksonian and systemic thinking (hence the name, Korzybski Institute) as well as many perspectives of therapy and training therapists. He co-founded the Korzybski Institute in 1982. His previous position was Chief of the Dept of Psychiatry and Psychosomatics at St John’s Hospital in Bruges. Luc was taken by CDOI’s attention to the common factors as well as the importance of monitoring outcomes.

On a more content related note, Jesse Owen just turned me on to a great alliance article: Crits-Christoph, P., Connolly Gibbons, M, , Hamilton, J., Ring-Kurtz, S., Gallop, R. (2011). The dependability of alliance assessments: The alliance-outcome correlation is larger than you think. Journal of Consulting and Clinical Psychology, 79, 267-278. Once again, a very sophisticated study validates the focus of CDOI and PCOMS. 

This study found that session 3 alliance ratings accounted for 4.7% of the variance but the average of sessions 3-9 explained a whopping 14.7% of outcome variance. This study suggests that a single session view of the relationship between the alliance and outcome very likely underestimates its impact on ultimate treatment outcome. Bottom line: Don’t underestimate the power of the alliance! In addition they recommended ongoing alliance assessment with alliance measures that don’t put too much burden on clients but that are reliable and valid. Do you know of any?

Don’t forget the upcoming webinar on supervision (Supervision Matters: Tapping into Therapist Aspirations to Get Better) coming up this Thursday, June 30 at noon Central. Join the CDOI member site to catch this one and many others.

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Duncan, B. (2011). What therapists want: It’s certainly not money or fame. Psychotherapy Networker, May/June, 40-43, 47, 62.
Duncan, B. (2011). Opening a path: From what is to what can be. Psychotherapy Networker, May/June, 46-47

On another important note, certified trainer and UK psychiatrist Sami Timimi has started a ‘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

Quotable quotes about diagnosis:
“Psychotherapy is the only form of treatment which, at least to some extent, appears to create the illness it treats” Jerome Frank (Frank, 1961, p. 7).

Reliability: “To say that we’ve solved the reliability problem is just not true…It’s been improved. But if you’re in a situation with a general clinician it’s certainly not very good. There’s still a real problem, and it’s not clear how to solve the problem” Robert Spitzer, lead editor of DSM III (Spiegel, 2005, p. 63).

Validity: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it… these concepts are virtually impossible to define precisely with bright lines at the boundaries.” Allen Francis, lead editor of DSM IV (Greenberg, 2010, p. 1).

You know how book covers are often adorned by endorsement quotes from prominent folks? Perhaps these quotes could appear on the upcoming DSM 5.

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And the completed and published project: Anker, M., Sparks, J., Duncan, B., & Stapnes, A. (2011). Footprints of couple therapy: Client reflections at follow up using a mixed method design in routine care. Journal of Family Psychotherapy, 22, 22-45. In this study, we explored client experiences of couple therapy using their written responses to questions at 6-month follow-up. We did a qualitative thematic analysis and a number of themes emerged along with client evaluations of those themes. We analyzed these with respect to the overall sample, gender, and the feedback/no-feedback groups in the original Norway Feedback Trial (Anker, Duncan, & Sparks, 2009). There were two general domains—relationship and tasks, that neatly fit Bordin’s definition of the alliance. Respondents were generally satisfied with the relationship domain, but there were more dissatisfied responses in the tasks domain. Basically, clients indicated that they liked therapists who were friendly, warm, and able to be neutral. There were more negative assessments of therapists not giving enough concrete suggestions, not challenging when appropriate, or not structuring the session. These findings did not differ significantly by gender and supported other the findings from similar studies. What was interesting had to do with the category “service delivery.” This category had the most statements in the tasks domain and there were more negative than positive. Clients were not happy with how the scheduling of therapy happened, the frequency of meetings, and lack of therapist follow-through on contacting clients between sessions and being flexible about scheduling. This was very interesting as this element of our work is rarely discussed in the literature, or training for that matter. But it is an important aspect of the alliance. Even more interesting, this was the one category that differed between the feedback and no-feedback groups, with no-feedback clients more dissatisfied with service delivery. We weren’t exactly sure what this meant, but speculated that therapists routinely getting and responding to feedback somehow were more attentive to their clients in these areas. We also asked couples what they thought of the feedback process. Over 60% of clients found it useful while less than 30% didn’t find it helpful. But the client’s goal for the relationship was important here. Of those clients who indicated that his or her goal was to improve the relationship, over 80% found the feedback process helpful.

Here is the article:

Finally, don’t forget this month’s webinar: Tuesday, May 31 at Noon Central: George Braucht and Neil Kaltenecker present: “Stand by Me: Recovery-Oriented, Person-Directed & Outcome Informed Peer Services”

This webinar highlights an application of CDOI skills and tools that blend the alcohol and other drug use recovery-oriented (RO) systems of care model with person (instead of client)-directed (PD) and outcome-informed (OI) peer-delivered services. As empirically demonstrated, transforming acute care models and techniques into CDOI services achieves improved efficiencies and outcomes that can contribute significantly to reaching the enhanced service goals fostered by the Parity and Affordable Healthcare laws. A key takeaway of this webinar is an example of how to integrate into existing services the experience, strength and hope of ROPDOI-trained people in long-term recovery along with the pervasive, culturally-diverse community resources for initiating and sustaining recovery. Building on Georgia’s seminal work on mental health peer specialists, the webinar focuses on the service delivery tools used by peer recovery coaches who have completed the Certified Addiction Recovery Empowerment Specialist (CARES) Academy. This webinar is suitable for behavioral, healthcare and social service providers and administrators; recovery community members; and others who are seeking or in long-term recovery. Participants who have not already seen Dr. Bob Bohanske’s webinar Operationalizing recovery: The Consensus Statement in Action are encouraged to view it before this webinar.

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