Some of you, given my previous critiques of EBT may be surprised by my answer, which is “yes.” EBT, however, must be taught within several larger contexts. First, EBTs should be taught within the context of what models and techniques bring to the table in therapy: namely, as Jerome Frank so eloquently noted, all models bring an explanation for the client problem and a remedy or solution for it. The important stuff that models offer is not their inherent truth across clients, but rather a rationale for the client’s problem and a ritual to solve it. In addition, as Rønnestad and Orlinsky so aptly argue from their research of now nearly 11,000 therapists, having theoretical breadth is a good thing—the breadth of our theoretical understandings enhances both our ability to attain healing involvement (the pinnacle of therapist development) and long term career growth—important reasons to take the theoretical plunge in many conceptual pools. There is a summary of Rønnestad and Orlinsky’s research in this article:

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

The next larger context is the alliance. In an important way, the alliance is dependent on the delivery of some particular treatment—a framework for understanding and solving the problem. The alliance cannot happen without technique. If technique fails to engage the client in purposive work, it is not working properly and a change is needed. Technique is an activity—the alliance is a way to characterize that activity; the alliance is the purpose of the activity. Although it is possible for a strong relationship to develop, there can be no agreement about the tasks of therapy, a critical aspect of the alliance, without some discussion and negotiation of what “treatment” will be used—be it some specific approach, the client’s own ideas and cultural preferences, or some unique blend.

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

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

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

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Protests continue about DSM-5. Recall the Division of Humanistic Psychology has mounted a significant challenge to the scientific credibility of the upcoming DSM (see previous blog) and has garnered over 8000 signatures on their petition (including mine). If you have not read their letter and signed, please consider it (visit here for more information). ABC News has just released another story on the DSM-5 controversy:
http://abcnews.go.com/Health/MindMoodNews/dsm-fire-financial-conflicts/story?id=15909673
And the consumer group Mind Freedom is planning a protest at the upcoming American Psychiatric Association’ Annual Meeting. Here is the press release:
Protesters, Rejecting Mental Illness Labels, Vow to “Occupy” the American Psychiatric Association Convention

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

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

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

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

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

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

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

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

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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!

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.

The first annual Heart and Soul of Change Project Training of Trainers Conference occurs next week in West Palm Beach. It looks like a talented group of participants and I am excited to be a part of it. Bob Bohanske and Jacqueline Sparks, Project Leaders, will be joining in toward the end of the week. As I have reflected about what I thought the six most important things that the TOT should cover and what people should understand, I came up with the following list:

• Dodo Verdict: Implications for Psychotherapy as well as the EBT v. EBP Controversy
• Common Factors: The Heart (the Client) and Soul (the Alliance) of Change
• Rationale for Practice Based Evidence and the Power of Feedback
• The Predictors of Ultimate Outcome (Early Change and the Alliance)
• The Clinical Nuances of Using the Measures and Making them Meaningful to the Work
• The Keys to Agency Implementation including Culture Building, Integration at All Levels, and especially, Supervision

There are more to be sure and client privilege is built in to each of the above. But this seems to capture the stuff that forms the foundation of an understanding of client directed, outcome informed clinical work.

Speaking of the EBT v, EBP controversy, I did a webinar last Friday for the CDOI Members (now over 300 and growing). Here is the description:
In this seventh of seven webinars corresponding to the seven chapters of On Becoming a Better Therapist, Barry discusses the fifth and final step to keep your development on the front burner and accelerate your growth as a therapist, the Treasure Chest. This collection of client comments about your work with them and your own articulations of the experiences that meant the most to your development help you to re-remember why you became a therapist while tracking your development as a therapist through narrative accounts of the clients who taught you the most. Barry will also discuss the controversial issues of the day–managed care, evidence based practice, psychiatric drugs, and the medical model–and encourage you to take a stand to protect the aspects of your identity as a therapist that you hold dear.

Why am I telling you this if you not a member? Because I messed up when I presented it the first time and didn’t record the video portion of the presentation. Chalk it up to old age or whatever. So I had to do it over for the members but the good news is that it left me with an audio recording that I can make available to anyone interested. So here it is.

And speaking of the book, here is a review that appeared in Psychotherapy in Australia, by experienced clinician Bill Robinson.

Do you think you have ever been duped in therapy? I had the opportunity to contribute to the Kottler and Carlson book, Duped, which was great fun because it allowed me to talk about two clients who taught me a lot about what is important in therapy. The first one really stretched my ability to believe clients, taught me that being a reality police officer is not likely to help form a strong alliance, and convinced me that the least I can do is believe my clients. The second client taught me that sometimes a lie can be therapeutic, perhaps just what is needed to allow resolution to occur. Check it out:

And don’t forget the new free webinar on December 29th 6:00 to 7:30 Central (and the previous one for Chapter Five is posted): On Becoming a Better Therapist: Chapter Six Discussion. This chapter keeps the focus on you, encouraging you to envision your identity as a helper and further contemplate this unpredictable and complexly human enterprise called therapy. It takes a whimsical look at therapist identity using the classic fable, The Wizard of Oz, to illustrate three different therapist personas. Concomitant to reflection about your identity is your personal description of what therapy means to you. This chapter encourages you to define and continually edit your personal rendition of what you do as a therapist. Psychotherapy is presented as a discovery-oriented process, a non-cookie cutter search for what works for each unique client. Feedback provides a comforting compass, a way to manage the uncertainty that is just as characteristic of therapy as it is of life.

Register now at: https://www2.gotomeeting.com/register/537803827

I am back from Rome and it was quite an inspiring experience on many levels. Rome is an enchanting and spiritual city. As many of you know who have read the preface to Heroic Client, I have been following the kid and psychiatric drug issue for the duration of my career. And as much as the data doesn’t support the prescription of psychiatric drugs to children, the practice has skyrocketed. It has at times been a very disheartening experience when the concerns are so quickly discounted, not only by psychiatrists but also by almost everyone else. I can’t tell you how many times people just dismiss it out of hand and have thought I was a fruitcake (or anti drug or anti psychiatry or even anti science) for even bringing it up. Keep in mind that this attitude persists despite the fact the data clearly show that drugs should never be a first line treatment, especially for kids. This doesn’t mean that they are never helpful.

But most did not dismiss us in Rome, esppecially the people that can make a difference. The presentation was very well received and got some very good publicity (http://www.catholicreview.org/subpages/storyworldnew-new.aspx?action=9117) Furthermore, we received strong support from various Vatican officials and there is hope for doing an international, multi-religion conference in Rome about this. The implications here are quite exciting.

Here is the text of presentation:

Here are the slides from my presentation. 

And I also made three short videos from around Rome about my presentation which will be up in a couple of days.

A final note about Rome. This would have never happened without the persistence and dedication of Marcia Barbacki. She has selflessly worked on this project for several years and doesn’t know how to take no for an answer. Long after I held little hope for getting the Vatican involved in this issue, Marcia continued to lobby until she succeeded in getting me on this recent program which led to many opportunities for further meetings.

On another note, the next free webinar is scheduled on December 29th 6:00 to 7:30 Central (and the previous one for Chapter Five is posted): On Becoming a Better Therapist: Chapter Six Discussion. This chapter keeps the focus on you, encouraging you to envision your identity as a helper and further contemplate this unpredictable and complexly human enterprise called therapy. It takes a whimsical look at therapist identity using the classic fable, The Wizard of Oz, to illustrate three different therapist personas. Concomitant to reflection about your identity is your personal description of what therapy means to you. This chapter encourages you to define and continually edit your personal rendition of what you do as a therapist. Psychotherapy is presented as a discovery-oriented process, a non-cookie cutter search for what works for each unique client. Feedback provides a comforting compass, a way to manage the uncertainty that is just as characteristic of therapy as it is of life.

Register now at: https://www2.gotomeeting.com/register/537803827

I have a presentation coming up soon at the Vatican at a conference about equitable health care. I am presenting about social justice, kids, and psychiatric drugs so I have been researching, with my colleague Jacqueline Spark’s help, the latest information. I found some pretty disturbing stuff regarding the differential prescription rates of poor kids. A study of 11,700 children under age 18 covered by Medicaid found that the number of children newly treated with antipsychotics increased from 1,482 in 2001 to 3,110 in 2005 (Mathak, West, Martin, Helm, & Henderson, 2010). In other words, a staggering 26% of kids in this sample were taking antipsychotics. Another study found that children covered by Medicaid were prescribed antipsychotics at a rate four times higher than children with private insurance, and were more likely to receive antipsychotics for unapproved uses (Crystal, Olfson, Huang, & Gerard, 2010), or in other words, for reasons of control, not treatment. A study of foster care children found that 57% received three or more drugs (Zito et al., 2008), six times the national average in spite of the fact that no research supports more than one drug for kids. Finally, the use of antipsychotics with privately insured children, aged 2 through 5, has doubled between 1999 and 2007 (Ofson, Crystal, Huang, & Gerhard, 2010). About 1.5% of all privately insured children between the ages of 2 and 5, or one in 70, received some type of psychiatric drug in 2007 despite the fact that there is little to no evidence in this age group.

When you consider the research of antipsychotics with kids (the TEOSS study found that only 12% of kids benefited from antipsychotics and that serious adverse events were all but guaranteed), this is quite a distressing situation. My presentation and the resulting paper will call for a higher standard of prescriptive care. Where children are concerned, the stakes are higher. They are, essentially, involuntary patients—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). Moreover, poor children often have fewer adults watching over them and are vulnerable to dangerous drugs used as interventions of control rather than therapy, and therefore require more care to ensure equitable treatment. The evidence demands that the trend of rising prescriptions and lower psychosocial intervention be stopped and a higher standard of care implemented: 1) psychosocial intervention should be considered first–families and youth should have a voice in decisions about their care, especially the disenfranchised; 2) no off label prescribing; 3) no polypharmacy; 4) immediate separation of the pharmaceutical company influence from science and practice; and 5) monitoring treatment response with consumer rated measures. My presentation will call for a higher standard of care for our most vulnerable and precious commodity, our children, that invites unity among all concerned health professionals. It is time to no longer accept prescriptive practices that do not follow the evidence and increasingly put clients at perilous risk for serious health consequences, dependence, and disability. Read more about psychiatric drugs here and watch a video here.

On another note, we have applied for evidence based treatment status with SAMHSA thanks to the Norway Feedback Trial (congrats to Morten Anker on his Ph.D., just conferred this week) and the two RCTs by Jeff Reese. I’ll keep you posted.

Finally, don’t forget the free webinar this month about my book, On Becoming a Better Therapist: November 23rd at 6:00 PM Central. Register now!

Call me cynical but it seems that the field is not really sure what professional development means or how we can accomplish it. First up to bat, of course, were the psychodynamic folks who told us that developing ourselves as psychotherapists required that we become more self-aware through personal therapy. This makes a lot of intuitive sense and gaining an appreciation of what it is like to sit in the client’s chair seems invaluable. But the cold hard truth is that personal therapy and “self awareness” has nothing to do with outcome—it neither helps nor hinders. Strike one.

Then along came family therapy, the antiestablishment poster kids who rejected analysis and decided to train therapists differently: watch the moves of the masters, they said, and replicate them. It took these renegades, the family therapists, to bring intervention and training to its highest art form. What swashbuckling enactments, what breathtaking chair moving, what heartrending sculpting! From falling off chairs to invariant prescriptions, to symptom prescription, to washing floors at 3:00 A.M., family therapy training rose to new heights of . . . of entertainment. Audiences thrilled, readers gasped. Therapists did their best impersonations of the masters. But that didn’t help outcomes either.

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. The “right approach,” however, evidenced based treatments or the everyday variety, doesn’t matter much to outcome. No one approach has ever shown it is better than any other. This, of course, is the famous dodo bird verdict (“All have won and all must have prizes.”), taken from the classic Lewis Carroll tale, Alice in Wonderland, first invoked by Saul Rosenzweig way back in 1936 to illustrate the equivalence of outcome among approaches.

And, although the need and value of training seems obvious, it has long been known that training doesn’t seem to matter much to outcome. And a just published study just adds to this less than inspiring fact. In the Journal of Counseling and Development, researchers Nyman and Nafziger reported that it didn’t matter if the client was “seen by a licensed doctoral–level counselor, a pre-doctoral intern, or a practicum student,” concluding that “It may be that researchers are loathe to face the possibility that the extensive efforts involved in educating graduate students to become licensed professionals result in no observable differences in client outcome.” As for continuing professional education, there is no research about it. The bottom line is the professional training, continuing education, and the search for the right approach result in no observable differences in outcome. Strike two.

So what about experience? Surely, years of clinical encounters make a significance difference in outcome. But are we getting better, or are we having the same experience year after year? More bad news here: Experience just doesn’t seem to matter much. A look at the bible (Garfield and Bergin’s Handbook of Psychotherapy and Behavior Change) reveals that in large measure, experienced and inexperienced therapists achieve about the same outcomes. So, personal awareness, training, and experience don’t make us better. Strike three, yer out!

And finally, regardless of our methods of getting better, we are quite self-delusional about our effectiveness. Consider a study reported by Vanderbilt researcher Len Bickman and associates: Clinicians were asked to rate their job performance from A+ to F. Two-thirds considered themselves A or better. Not one therapist rated him or herself as below average. If you remember that thing called the Bell curve, you know this is not possible. But it’s not their fault! In the absence of reliable information, how could they know? How can you know?

Does this mean that you should take your bat, glove, and ball and go home and forget the whole thing? Nope. Whether you are a novice or a seasoned veteran, becoming a better therapist requires you to be proactive about your growth as a helper In spite of oppressive paperwork, daunting productivity requirements, and funder mandates, you must take your development personally to remain a vital force in client lives. And contrary to my cynical portrayal the state of the field’s efforts to help you get better, there is an empirically-based method arising from the most extensive investigation of therapist development ever conducted. The findings of that study, combined with advantages of tracking outcome with clients provide just the ticket to making you a better therapist. Read about it here:

I recently did an exchange with a reviewer of The Heart and Soul of Change: Delivering What Works (2nd Ed.):

The Heart and Soul of the Dodo: A Review of The Heart and Soul of Change (2nd Ed.)

Thomas L. Rodebaugh

“The time has come,” the Walrus said, “To talk of many things.”

In The Heart and Soul of Change: Delivering What Works in Therapy, considerable attention is paid to establishing that Saul Rosenzweig was the original articulator of the dodo bird hypothesis: All psychotherapies work about equally effectively. Let us look closer at the source of the quotation, found in Alice in Wonderland, “Everyone has won, and all must have prizes!” (Carroll, 1865 and 1871/1998, p. 49).

In the story, an assortment of animals and the protagonist, Alice, have become drenched in a sea of Alice’s own tears. The ensuing “Caucus-race” (Carroll, 1865 and 1871/1998, p. 48) is the dodo’s invention to motivate the creatures to dry themselves off. It is not actually a race to be won, which is also demonstrated by the pitiful prizes: Each animal receives a single comfit (a candied, dried fruit). Because the animals eat all of those, Alice herself receives a thimble. More precisely, she keeps a thimble, because the comfits and the thimble were her own to begin with.

The dodo bird’s statement is not meant to be a hypothesis: It is meant to quiet the animals. Taken literally, the declaration regarding winners and prizes is clearly intended as nonsensical. The dodo, otherwise best known as a dead bird, is thereby made immortal as a purveyor of nonsense. Rosenzweig’s use of the dodo as a witty epigram some 74 years ago was inspired; that the dodo should live on as a metaphor for psychotherapy research so many years later strikes me as truly strange.

The dodo is a strong force in The Heart and Soul of Change. The book is a series of chapters by different authors but maintains a structure largely focused on the dodo bird hypothesis, its historical context, the research that can be taken to support it, and its implications for practice. Much of the rest of the book consists of further demonstrations that the dodo bird hypothesis is the most sensible interpretation of the data, set alongside critiques of empirically supported therapies (ESTs) and policies that support their adoption. Some later chapters focus primarily on what should be the next steps given that the dodo bird’s viewpoint is better supported than is a viewpoint that emphasizes ESTs.

Any adherents to ESTs who stumble upon the book might be forgiven for thinking they had accidentally landed in the mirror world described in Lewis Carroll’s other famous adventure for Alice: They are likely to cry foul, that evidence has been distorted and conclusions have been drawn contrariwise. Most (but not all) of the authors opine that ESTs offer no advantage and have been massively overblown and overpromoted.

Yet supporters of ESTs will probably already have to hand several recent challenges to the dodo (e.g., Ehlers et al., 2010). Among these counterpoints, I find particularly lucid Siev and Chambless’s (2007) demonstration that one must examine specific treatments for specific disorders to uncover differences between treatments. Supporters of ESTs might question why such findings are not responded to in this book. Certainly at least Siev and Chambless’s meta-analysis was available at the time of the writing of the chapters. Such apparent stacking of the deck does little to persuade people already inclined to support ESTs.

This book is clearly not aimed at such readers; neither is it, despite the title, primarily aimed at individuals looking for a how-to book regarding common factors in therapy. Although a chapter by Norcross, “The Therapeutic Relationship,” presents an excellent summary of these factors and the research that has investigated them, very little evidence is given as to how these factors can be better brought to bear in therapy. That is, although it seems clear that (for example) a stronger therapeutic alliance is desirable, there appears to be little systematic research available to establish that any particular intervention (e.g., a type of therapist training) necessarily improves alliance (although feedback, dealt with below, is held up as an exception to this general rule).

In fact, in another chapter, Wampold indicates that piecemeal investigations of one of the common factors cannot be conducted successfully: “The presence or absence of a common factor cannot be manipulated” (pp. 72–73). If this were accurate, then true experiments regarding common factors would be impossible and their causal role would remain unclear to the many researchers and clinicians who rely upon strong causal inference to understand the nature of treatment (cf. Borkovec & Miranda, 1999).

For whom, then, is the book intended? People who are amenable to the dodo bird hypothesis or find support of ESTs misguided are most likely to find the book palatable, and presumably this is the target audience. It seems likely that many of the authors would like policy makers to read the book, although I am not sure how likely that outcome is. Although it might seem a curious recommendation, I suggest that those who most strongly believe that ESTs are valuable could benefit from reading this book. I do not think this book will likely sway many such readers, but I do think it will be very helpful in illuminating the concerns of the researchers and clinicians who find adherence to ESTs misguided.

As most readers will have probably already guessed, I myself am convinced of the value of ESTs, at least for some disorders. Nevertheless, I can see many of the authors’ points. Although the repetitive dismissal of ESTs and related research, found chapter after chapter, seems excessive (like beating a dead dodo), my primary disappointment in the book is that it contains so little information regarding what changes an individual practitioner could make that are known to improve outcomes. In short, readers looking for guidance in employing the common factors (aside from feedback) might do better to read the Norcross chapter and follow it with seminal work by previous authors (I have my own favorites: Rogers, 1961; Wachtel, 1993) rather than read the entire book.

The major concept put forward for improving the common factors is gathering systematic feedback from clients, focusing on avoiding or mending ruptures in the therapeutic relationship; two full chapters (and additional space in other chapters) are devoted to demonstrating that such feedback is valuable and can have effects in community mental health organizations. These chapters appear longer on promise than on specific guidelines on what works and what does not.
Much additional research needs to be done, but the point regarding the general value of feedback is well taken and should be well considered by any practicing clinician. Devotees of cognitive therapy might nevertheless find perplexing the news that “of course, one need not choose between giving feedback and using empirically supported treatments. They can work in concert” (see Lambert’s chapter, “‘Yes, It Is Time for Clinicians to Routinely Monitor Treatment Outcome,” p. 249). Feedback from clients in each session has long been emphasized by cognitive therapists (Beck, 1995).

Such verbal feedback does not match the technical and statistical sophistication of the processes reviewed in this book, but the same intent is there. That Lambert needs to point out that ESTs and feedback are, in fact, compatible speaks to a very strange disconnect, the fissures of which seem to run throughout the book.

Perhaps my underwhelmed reaction to this book speaks merely to the effects of my allegiances. Of course, the authors and editors have allegiances of their own, although I wonder if they are as uniform in those allegiances as it might seem at first glance. Upon a closer inspection, it seems to me that a range of understandings of the dodo hypothesis is expressed across chapters.

In the weakest form, the argument seems to assert merely that ESTs may have been overemphasized by some and that common factors deserve more research. In its strongest form, the argument seems to assert that (a) anything that therapists and clients can believe is a therapy will work as well as any other such treatment; (b) common factors explain virtually everything about the way therapy works, yet there is probably little that could be mandated that could improve their effects; and (c) naturalistic tracking of outcomes is perhaps the sole exception to (b) and can also conclusively demonstrate that therapy is useful. In the strongest form, then, therapy and therapists are treated as a set of black boxes: There is no way to systematically alter the functions of these boxes, yet one can select therapists and therapist/client dyads on the basis of results.

I find myself concerned that some readers, perhaps most particularly those who see ESTs as a magnifier of the bureaucratic nightmare of insurance company requirements, might too easily endorse the strong dodo hypothesis. The position might seem attractive because it basically implies that therapists should be allowed to do whatever it is they do.

However, this position strikes me as pregnant with unwanted consequences. If good therapy entails a special quality (in the therapist, client, or both) that cannot be systematically varied (that is, caused to be present in some courses of therapy but not others), then one might wonder why anyone should research psychotherapy at all.

It seems to me that rather than the (strong) dodo hypothesis, we would be better off listening, but just for a moment, to the walrus hypothesis: The time has come to talk of many things. The field of psychotherapy needs more research, using many approaches, at all levels; it does not need an excuse to leave well enough alone.

However, research is not the only consequence of the strong dodo hypothesis. Practice, too, could suffer. If being a good therapist cannot be systematically taught, who would want to pay for years of training? One might wonder: Why not let anyone, with any level of training, try out being a therapist? One could simply select those people who are able to get the best results while accepting a minimum wage (perhaps the minimum wage) as payment.

It seems to me that the strong dodo hypothesis supports a form of essentialism that will not do science, practice, or policy any good at all. Neither supporters of ESTs nor their detractors want to see the therapeutic practice of clinical psychology go the way of the dodo.

Some Therapies Are More Equal than Others? A response to the review of The Heart and Soul of Change: Delivering What Works in Therapy (2nd ed.)

Barry L. Duncan

Rodebaugh (2010) candidly admits his allegiance to empirically supported treatments (EST), which perhaps explains the myopic lens used to examine the book. The dodo verdict (“Everybody has won and all must have prizes.”) still perfectly describes the state of affairs in psychotherapy—all bona fide approaches, in spite of vociferously argued differences, appear to work equally well. It is the most replicated finding in the outcome literature. Commenting on the dodo verdict’s ubiquity is hardly “stacking of the deck” when the findings that contradict it are less than would be attributable to chance alone. Importantly, saying that the dodo verdict persists in no way suggests that specific treatments for particular problems are not helpful.

While we take a critical stance toward claims of model superiority and confirm the veracity of the dodo verdict across modalities and populations, we do not denigrate model and technique nor specific effects, but rather propose that model/technique are essential components of a common factors perspective. We offered a way to understand how 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.

We attempted to unite the warring factions via a more sophisticated understanding of change (interconnected factors, not disembodied parts or a tiresome specific v common factors polemic) as well as APA’s more contextual definition of evidence based practice. As the APA Task Force noted, the response of the client is variable and therefore must be monitored and treatment tailored accordingly to ensure a positive outcome. Proponents from both sides of the common versus specific factors aisle have recognized that outcome is not guaranteed, regardless of evidentiary support of a given technique or the expertise of the therapist. Monitoring outcome with clients, what has been called practice based evidence, has been shown to significantly improve outcomes regardless of the treatment administered. There are now nine RCTs showing the significant benefits of feedback (Duncan, 2010).

Rodebaugh’s assertion that one must examine specific treatments for specific disorders to uncover differences between treatments ignores the many direct comparisons that have not yielded any differences for specific disorders, like the TDCRP, Project Match, the Youth Cannabis Project, to mention a few (see Duncan et al., 2010). Consider the study we didn’t cite (Siev & Chambless, 2007). Although it is hard to imagine many therapists who would solely do relaxation training with panic, CBT beat relaxation alone on primary measures (although a closer look at the five studies reveals that one was significantly more positive than the other four, and two found very little difference). But even accepting this investigation at face value, that CBT is better than relaxation for panic (but not GAD) on primary measures only, hardly seems like any definitive overturn of the dodo verdict.

Nowhere in the book is there any suggestion that the dodo verdict implies that we should “leave well enough alone” regarding research, or perhaps the most egregious comment, that anything goes in the consulting room—or that there is little point to training. Quite the contrary, the book advocates for a shift toward research and training about what works and how to deliver it, and away from a sole reliance on comparative, “battle of the brands,” clinical trials. For example, my colleagues and I recently explored the relationship of the alliance to outcome and found that it predicted outcome above early treatment change and that ascending alliance scores were associated with better outcomes (Anker, Owen, Duncan, & Sparks, 2010), a strong argument for continuous alliance assessment. The book also calls for a more sophisticated clinician who chooses from a variety of orientations and methods to best fit client preferences and cultural values. Although there has not been convincing evidence for differential efficacy among approaches, there is indeed differential efficacy for the client in the room now—therapists need expertise in a broad range of intervention options, including ESTs, a point made by several authors.

Dismissing the book on the basis that some therapies are more equal than others is reminiscent of another set of animals in another classic story. It’s time to transcend the polemics and instead focus on what works with the client in my office now.

A Response to Barry L. Duncan

Thomas L. Rodebaugh

Let me emphasize that my reaction to The Heart and Soul of Change: Delivering What Works in Therapy was not uniformly negative. Further, I did not intend my review to be completely negative. I found the book useful overall; some chapters were particularly helpful. It would be a shame if the current debate were to overshadow that point.

The current format demands brevity. A point-by-point response to Barry L. Duncan (all the way down to Animal Farm) is untenable. The interested reader might re-examine my original review; my answers to some of Duncan’s statements are already implied there.

Allow me to focus on the term bona fide, upon which the current version of the dodo bird hypothesis rests. Bona fide treatments are treatments that are intended to be therapeutic. Intended by whom? Duncan expresses doubt that “many psychologists” would use relaxation treatment alone to treat panic disorder. I know one psychologist who would do so. I have informally polled my colleagues, who state that they have encountered others. Perhaps it is important that many psychologists believe that a treatment should work before it be considered bona fide. How many?

Without precise definition, whether something is bona fide is a subjective judgment. Studies could be dismissed because particular authors believe a treatment not to be bona fide or because they believe the researchers probably did not believe them to be bona fide, even if the researchers actually thought otherwise. I have had only modest experiences with clinical trials, but even I have seen many variations in level of belief at different levels of study teams. Sometimes therapists seemed to clearly believe more or less in particular conditions than did the principal investigator(s). Is it the therapists, investigators, or psychologists at large who count? Unless we define what level of belief is needed in the individual clinician or researcher, or how many psychologists must have such belief, our resulting decisions cannot be consistent (cf. Ehlers et al., 2010, for similar concerns).

Duncan seems to dismiss the idea that his argument indicates that “anything goes” in treatment. I can see his point, if bona fide means that “many psychologists” believe a treatment should work. We could thus be saved from endorsing ludicrous, fringe treatments. All the more reason to stringently define bona fide and thus reduce confusion among psychologists interpreting this literature.

Yet ineffective treatments sometimes have a popular following. As Ehlers et al. (2010) have pointed out, critical incident stress debriefing is certainly one example of a treatment that psychologists intended to be therapeutic but seems, upon investigation, possibly worse than useless. The hypothesis is that all (bona fide) treatments have won. To disprove it requires only one that has lost.

And don’t forget to register for the free webinars covering each chapter of On Becoming a Better Therapist: This month’s webinar covers Chapter 3 and will be on September 28th, 6-7:30PM Central. Register now at: https://www2.gotomeeting.com/register/945596986