Data Integrity, Agency Implementation, and More Research


Posted in Uncategorized on 08/30/2011 01:56 pm by Dr. Barry Duncan

Data Integrity, Agency Implementation, and More Research
My views about agency implementation have changed substantially in the last few years. I used to believe in allowing it to happen more organically with agencies coming to see how data collection was invaluable part of the CDOI/PCOMS implementation process. Implementation generally started with the practices that supported a client directed or client privilege process and then progressed to operationalizing client privilege with the ORS/SRS family of measures. And then, data collection would start. The problem is that when I would follow up and look at the data, it had no integrity—in short, it was not helpful to therapists or agencies. I now believe that implementation should start with data collection from the very beginning. Collecting data allows you know in a heartbeat who is doing it and who isn’t. It allows supervisors to attend data integrity issues—that the measures are being used properly—right from the get-go. The data provides a clear picture of fidelity and integrity. The major integrity issues to look for are: More than 30% over the clinical cutoff ; any scores between 35-40; and ORS scores are go up and down or look like a saw on a graph.
Here is a slide I made to reflect the importance of data.
div style=”width:425px” id=”__ss_9075706″> DataIntegrity

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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.

SRSSocDesDemandChar
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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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Implementing CDOI and PCOMS: The Heart and Soul of Change Project


Posted in Uncategorized on 07/30/2011 07:25 pm by Dr. Barry Duncan

There are five features of implementation of client directed, outcome informed (CDOI) clinical work and the Partners for Change Outcome Management System (PCOMS) that distinguish the Heart and Soul of Change Project:

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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Korzybski, Luc Isebaert, and the Alliance


Posted in CDOI, Common factors, PCOMS on 06/26/2011 04:13 pm by Dr. Barry Duncan

I just returned a few weeks ago from Europe which included training in The Netherlands, Switzerland, and Belgium which I did for Korzybski International. They run an extensive multiyear post graduate training program in Solution Focused Cognitive Therapy, which in Europe is called the Bruges Model as well as many other useful therapeutic ideas and practices. This was my second trip for them and the more I get to know them the more I have come to like what they are doing. This trip cemented my involvement in their training program and now CDOI and PCOMS will be a fixed feature of their training. There is now a formal affiliation between the Korzybski Institute and the Heart and Soul of Change Project. This is important because it will help spread the word to many who would have otherwise never heard of CDOI or PCOMS because of language differences. While many Europeans speak English, many do not as well. French speaking folks, for example, have had little exposure to the ideas (the first edition of Heroic Client was translated but it did not include the ORS/SRS) but no longer. There is a translation of the Heart and Soul of Change in the works and I am hopeful that On Becoming a Better Therapist will be next. And, I will be conducting training in France next year which hopefully inspire interest as well.

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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Networker Articles and an Anti-Labeling Campaign


Posted in Uncategorized on 05/30/2011 08:10 am by Dr. Barry Duncan

As promised, here are the articles appearing in the current May/June issue of the Psychotherapy Networker. Although difficult to condense an entire book to a few pages, I believe the two pieces capture the spirit of On Becoming a Better Therapist. I would have liked to include a bit more about how I think therapists can improve outcomes by specifically focusing on alliance skills, but space did not permit. However, I will be conducting a video webinar for the Networker that covers this ground.
Here are the citations. The articles follow.

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

WhatTherapistsWantOpeningthePath
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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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First RCT of Feedback with Kids and Adolescents and Another Study Published


Posted in CDOI, PCOMS, Research, feedback on 05/12/2011 01:13 pm by Dr. Barry Duncan

As I have said before, the reason that we are called the Heart and Soul of Change Project is because we are committed to both creating and disseminating research from naturalistic sites that operationalize our mission to privilege the client’s voice and enter true partnerships with those we serve. That is our ongoing project. Besides the ones I mentioned in the “Bob Bohankse Land” blog, there is another project well underway in one site and beginning in another and a completed one that just made the light of day in the Journal of Family Psychotherapy. The first randomized clinical trial of feedback ever done with children and adolescents in the schools (or anywhere else) has been underway for some time in Mary Haynes Land, otherwise known as Maine and Community Health and Counseling Services. This project has been a collaborative effort of Mary Haynes (who is also a Project Leader of the HSCP) and Liam Shaw, a supervisor of the Skowhegan office (and several dedicated therapists) with the ongoing support of Executive Director Dale Hamilton. Another site has just signed on, thanks to the leadership of Bob Bohanske and the support of the President of Southwest Behavioral Health, Jeff Jorde. Also part of the Phoenix team are Vice President Ed McClelland and Clinical Supervisor Alysson Zatarga, who will really be the ones making it happen. This study could really make a difference in how services are delivered in the schools, ensuring that kids and adolescents have a voice in decisions about their care. This study is an collaborative of Barry, Project Leader and UCA Professor John Murphy, and Art Gillaspy, Associate Professor at UCA. Considering the impact the Norway Couple Feedback Trial had on how couple services are delivered in Norway, this study could change the way services are provided in the schools.

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:

FootprintsCoupleTherapy
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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.

Join the member site now and start enjoying the benefits of 24/7 affordable training.

 

We Make Less Than…No Way!


Posted in Becoming a Better Therapist, drugs on 04/19/2011 12:09 pm by Dr. Barry Duncan

Survey Finds Behavioral Health Professionals Earn Less Than Fast Food Workers

Washington DC (April 11, 2011)—According to the 2011 Behavioral Health Salary Survey just released by the National Council for Community Behavioral Healthcare (National Council), the nation’s mental health and addictions treatment professionals are paid far less than their counterparts in other healthcare sectors.

“Just as people with mental illnesses and substance-use disorders are routinely stigmatized, it appears those working in the behavioral health sector are also treated differently—even within the healthcare community,” says Linda Rosenberg, National Council president and CEO.

The survey of more than 850 mental health and addictions treatment organizations finds:
• A direct care worker in a 24-hour residential treatment center earns a lower median salary ($23,000 a year) than an assistant manager at Burger King ($25,589).
• The annual salary range for a chief medical officer at a behavioral health organization is $101,000–$150,000, compared to the national average of $183,947–$292,395 for the same position in any other type of healthcare organization.
• A social worker with a master’s degree in a mental health-addictions treatment organization earns less ($45,344) than a social worker in a general healthcare agency ($50,470).
• A registered nurse working in a behavioral health organization earns $52,987 compared to the national average for nurses of $66,530.
• “The survey underscores the need to end the second class status of employees working in mental health and addictions organizations,” says Rosenberg, who cites the recent economic crisis and state budget cuts for contributing to the problem.

“Until we achieve equity with the rest of the public healthcare safety net, we will continue to struggle to recruit and retain the number and caliber of professionals needed for more efficient and effective mental health and addictions services.”

The survey, conducted in partnership with the National Association of Addiction Treatment Professionals, includes salary data for executives, administrators, clinicians, direct care and support staff in public and private behavioral healthcare organizations. Completed in November 2010, survey findings are based on salaries reported by 860 respondents from 46 states, Puerto Rico and the District of Columbia. Annual salary data are based on the time period between July 1, 2009 and June 30, 2010.

The full report is available for purchase at www.TheNationalCouncil.org. For more information, contact Meena Dayak at MeenaD@thenationalcouncil.org

But of course, we don’t do this work because we thought we would attain the lifestyles of the rich and famous, and we knew that what we do is not particularly valued by our culture at large given funding cuts, etc over the years. So why do we do it? If you have read my recent book, you know the answer according to the largest study of therapists ever done, a massive 20-year multinational study of 11,000 therapists conducted by researchers David Orlinsky of the University of Chicago and Michael Helge Rønnestad of the University of Oslo (both contributors to the venerable Handbook of Psychotherapy and Behavior Change)–we do for the intrinsic reward of the work, attaining what these authors call “healing involvement” with our clients. But there’s no free lunch here–we have to work on our development to have these kind of quality experiences with our clients. My upcoming May article in the Psychotherapy Neworker addresses what you have to do make them happen. As soon as it is available, I’ll post it to the blog.

On the lighter side, are you looking for that silver bullet cure or magic pill, that perfect intervention for all the situations that clients bring us?

Here is the silver bullet cure. Pay attention to how the therapist carefully considers the client’s feedback:

And the magic pill:

Don’t forget Bob Bohanske’s webinar this Friday. Become a CDOI Member!

 

Bob Bohanske Land: Two New Exciting Projects


Posted in CDOI, PCOMS, Research on 04/05/2011 07:46 am by Dr. Barry Duncan

I usually don’t write on this blog about the places I visit to do training because I don’t really want the blog to be a twitter accounting of my travels to exotic and not so exotic places. But I have to talk about my travels this week to Bob Bohankse land, otherwise known as Phoenix, Arizona. I conducted a two-day training: one day was an overview of CDOI for the new folks and the second day covered the clinical nuances of getting the max out of the measures and the four steps of CDOI supervision for the seasoned staff members and supervisors. But I went a day early and stayed an extra day so Bob and I could work on and prioritize the many projects (that is the reason that we are called the Heart and Soul of Change Project because we are committed to doing things to both create and disseminate research from naturalistic sites that operationalize our mission to privilege the client’s voice) that would advance the state of knowledge about CDOI and PCOMS and therefore further help to spread the word. Although there are several, two in particular deserve special mention. First is an article to discuss the incredible data that Bob’s agency, Southwest Behavioral Health has collected. Bob has data on over 6000 clients and the results are nothing short of phenomenal, both for kids and adults. As a teaser, here is a piece of the data offering a comparison to services delivered without CDOI and PCOMS:

Children with CDOI: Achieved reliable change on average (including caretakers) and 47% achieved all goals (v. 32%) in 128 less days.
Adults with CDOI: Achieved reliable change on average and 33% achieved all goals (v. 19%) in 138 less days.

The article also proposes that that CDOI and PCOMS not only offer a way to improve outcomes while increasing productivity and saving money, it also operationalizes the vision of “recovery” as described by the SAMSHA and the Consensus Statement of Recovery. Bob will be presenting a webinar about Operationalizing Recovery and his data on April 22. Sign up for the members site now!

The second project is joint project of Southwest Behavioral Health, the Erikson Foundation, and the Heart and Soul of Change Project, and it is redo of the “Impossible” Case Project I did way back in the early to middle 90’s that culminated in the book Psychotherapy with “Impossible” Clients. This was an inspiring project that really changed the way that I did psychotherapy. I am very proud of that project and what we found but I really didn’t know what I was doing, research wise. There were no quantitative findings and no systematic assessment of outcome or of the chart review process. Further, although I conducted interviews with all the clients at termination, it was not a systematic qualitative inquiry and therefore didn’t mine all the golden data that was there. But this project will. It will repeat the study of clients who have had multiple treatment failures and pursue their experience and perceptions of why those failures occurred as well as why the current round produced a different outcome (hopefully). The project will include Bob, me, and Jacqueline Sparks (our qualitative consultant), as well as Lynette Small and Heath Kilgore (Southwest Behavioral folks).

 

Recent Special Journal Issue Further Confirms CDOI Practice.


Posted in CDOI, Common factors, Evidence based treatment, Research on 03/15/2011 07:20 pm by Dr. Barry Duncan

A special issue of the Journal of Clinical Psychology: In Session (February, 2011) addressed a topic near and dear to the hearts of CDOI therapists: Adapting Psychotherapy to the Individual Patient (sic). Here are some highlights.

Preferences: In this meta-analysis, we summarize results from 35 studies that have examined the preference effect with adult clients. Overall, clients who were matched to their preferred therapy conditions were less likely to drop out of therapy prematurely (OR=.59, p<.001) and showed greater improvements in treatment outcomes (d=.31, p<.001). Type of preference (role, therapist, or treatment type) was not found to moderate the preference effect. These results underscore the centrality of incorporating patient preferences when making treatment decisions. Swift, J.K., Callahan, J.L. & Vollmer, B.M. Preferences. Journal of Clinical Psychology: In Session, 67, 155–165.

Matching client preferences or privileging client ideas is what CDOI is all about in general, and what exploring the client’s theory is about specifically–the client’s view of the problem and how it may be best addressed including the role of therapist and the choice of any given explanation of and remedy to the problem.

Expectations: Patients’ expectations have long been considered a contributory factor to successful psychotherapy. Expectations come in different guises, with outcome expectations centered on prognostic beliefs about the consequences of engaging in treatment. Our research review includes a comprehensive meta-analysis (N =8,016 patients across 46 independent samples) of the association between pretherapy or early-therapy outcome expectations and posttreatment outcomes. The overall weighted effect size was d=.24, p<.001, indicating a small but significant positive effect of outcome expectations on adaptive treatment outcomes. Constantino, M.J., Arnkoff, D.B., Glass, C.R., Ametrano, R.M., & Smith, J.Z. (2011). Expectations. Journal of Clinical Psychology: In Session 67, 184–192.

Enhancing client expectations for success is part and parcel to CDOI clinical work. Monitoring outcome and conveying that the therapy is about change builds on expectancy effects as does matching client preferences about intervention. The alliance, expectancy, and model/technique are 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. 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

Culture: We present an original meta-analysis of 65 experimental and quasi-experimental studies involving 8,620 participants. The omnibus effect size of d = .46 indicates that treatments specifically adapted for clients of color were moderately more effective with that clientele than traditional treatments. The most effective treatments tended to be those with greater numbers of cultural adaptations. Mental health services targeted to a specific cultural group were several times more effective than those provided to clients from a variety of cultural backgrounds. We recommend a series of research-supported therapeutic practices that account for clients’ culture, with culture-specific treatments being more effective than generally culture-sensitive treatments.  Smith, T.B., Domenech Rodríguez, M., & Bernal, G. (2011). Culture. Journal of Clinical Psychology:In Session, 67, 166–175.

And of course, we believe that being outcome informed allows one to be more culturally sensitive. Privileging the client via practice based evidence 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.

Don’t forget the upcoming webinar: Become a CDOI Member!
Title: Barry Duncan – Therapeutic Work: It’s Not Just for Clients Anymore; Date: Monday, March 28, 2011;  Time: 12:00 PM – 1:00 PM CDT

 

Sometimes Being a Therapist Is the Worst Job…


Posted in Becoming a Better Therapist, CDOI on 02/22/2011 08:43 pm by Dr. Barry Duncan

Sometimes being a therapist feels like the worst job on earth: worse than tarring roofs in Miami in August, draining septic tanks, or being the new Star Trek crewmember who just beamed down to a hostile planet with Kirk, Bones, and Spock. Media depictions of therapists tend to cast us as crackpots and we are often blamed for creating a nation of wimps or otherwise causing the decline of western civilization with our encouragement of self indulgence, preoccupation with feelings, and Stuart Smalley daily affirmations. Then there is the economic situation. Our culture just doesn’t seem to value what we do. While some still thrive in private practice, most of us make far less than we did during the so-called golden era of insurance reimbursement. And, for many in public behavioral health settings, continual cutbacks and the pervasive threat of layoff are a way of life. The typical therapist working in an agency faces many hardships—seemingly unattainable productivity requirements, insurmountable paperwork, and more and more intrusive funder oversight. And this does not even speak to the emotional downsides of the work, the sometimes overwhelming tragedy of the human condition that seems inured to our best efforts—the stories of suffering that are sometimes hard to shake.
Here are two very funny, jaded (but sadly true in parts) accounts of the downsides, one addressing becoming a clinical psychologist and the other about becoming an MSW.

But we don’t do this work because we thought we would acquire the lifestyles of the rich and famous or the adoring eyes of a grateful nation; and we knew at the outset that mixing it up in the morass of human misery would not be a walk in the park. It is amazing to think, especially in these hard economic times that smart, creative individuals make the necessary sacrifices to attain advanced degrees only to earn far less money than those with comparable education in other fields—and willingly face a constant pelting of the pitfalls of being human. Doing the required servitude without the promise of a rags to riches future only makes sense because being a psychotherapist is more of a calling than a job—a quest for meaningful activity and personal fulfillment as well as an altruistic desire to be useful to others. This says something quite good about us and our career choice, something characteristic and perhaps idiosyncratic about us.

But many of us are battle weary, even shell shocked, and in the face of media ridicule, cultural devaluation, and financial uncertainty may have all but forgotten why we enlisted in the therapy rank and file in the first place. How does a therapist on the front lines keep going?

The answer may surprise you. More on that next time. That’s what On Becoming a Better Therapist is all about.

Don’t forget to join the member site so you can check out the upcoming Webinar addressing case management by Dr. Mary Haynes. Here’s the blurb: This workshop explores the ground-breaking expansion of the use of feedback to case management services. Based on her eight years of experience in extending the use of outcome management to settings other than traditional therapy, Mary will address the unique benefits and challenges of incorporating client feedback in community-based work with adults.

 

Making an Impact with Research–No Lip Service


Posted in CDOI, PCOMS, Research, Uncategorized, feedback on 02/08/2011 08:33 pm by Dr. Barry Duncan

The Heart and Soul of Change Project (HSCP) is a practice-driven, training and research initiative that focuses on what works in therapy, and more importantly, how to deliver it on the front lines via client based outcome feedback, or what is called the Partners for Change Outcome Management System (PCOMS). Consequently we are not just interested in capitalizing on what others do; rather the HSCP team produces research and directly translates it to clinical practice in the real world. The Norway Feedback Trial and Alliance Study is a case in point–these studies led to national implementation of PCOMS in Norway. And the hits just keep coming. First, the third randomized clinical trial (RCT) demonstrating the dramatic improvement in outcomes provided by merely adding feedback to therapeutic mix via the ORS and SRS is now in print. This is the replication study of the Norway Feedback Trial and it is an uncanny replication. This study found almost identical findings: four times as many couples achieved clinically significant change and the effect size for feedback was .49. Congratulations to Jeff Reese, Project Leader of the HSCP, and his research team for helping put CDOI and PCOMS on the map. This study culminated in our submission to SAMSHA for evidenced based treatment status (more on that later as well as the important distinction between evidence based treatment and evidence based practice).
Here is the study:

ReeseTolandSloneNorsworthy2010
View more documents from Barry Duncan.

We have three RCTs in progress: one with returning veterans, one with kids in the schools, and one study seeking to ferret out what really causes the feedback effect, or what is called a component study. Stay tuned.

Next in print is the “Footprints” article to appear next month the in Journal of Family Psychotherapy. This article looked at 6 month follow up data from the Norway Feedback Trial. As just a teaser of a study that reaffirms the importance of the alliance plus throws in a few curves, we found that clients in the non-feedback group were significantly more likely to complain about the therapy service delivery than feedback clients. More on this next month.

And a soon to be published (in the 2nd edition of the John Norcross book, Psychotherapy Relationships that Work) meta-analysis of PCOMS studies conducted by feedback pioneer Michael Lambert and K. Shimokawa found that those in feedback group had 3.5 higher odds of experiencing reliable change and less than half the odds of experiencing deterioration.

Finally, check out the next webinar by Dr. Mary Haynes: Creative Applications: CDOI in Case Managment
This workshop explores the ground-breaking expansion of the use of feedback to case management services. Based on her eight years of experience in extending the use of outcome management to settings other than traditional therapy, Mary will address the unique benefits and challenges of incorporating client feedback in community-based work with adults.

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