I recently answered four interesting questions about my clinical work for a Danish publication:
1) What is the most unusual or odd form of therapy/method you’ve ever had to go about to ensure an effective therapy and a good alliance with a client?
The client that comes to mind is Natalie. Natalie told me she’d been a multiple personality since childhood when her different alters provided protection from a brutally abusive environment. She felt she had already dealt with the abuse and didn’t want to become integrated into a single self, but rather wanted “co-consciousness,” a state in which the alters would be aware of each other’s experience without losing their separate identities. Natalie entered therapy because she had lost access to some of her most intuitive subselves.

I didn’t have any idea of how to help Natalie recontact her missing alters or promote co-consciousness. I shared my lack of experience in these matters and Natalie responded that her doctor had referred her, had said good things about me, and that she trusted her completely. Besides, she added, the previous therapist, a dissociative identity expert, had all but demanded that Natalie give up her alters in service of an integrated personality. Natalie wanted nothing to do with that. Natalie told me that she didn’t fit the mold of how that therapist thought about multiples, and added, “I can’t help that!”

But I was willing to not know—to explore her world, to find out how her system worked, to validate it, and try to discover a way to help her re-access her alters. Natalie was quite remarkable: witty, obviously bright, and very artistic. She worked as a copy editor for a magazine by day and by night was an accomplished oil painter. Over the next few sessions, Natalie and others in her system explained to me that her alters lived in various rooms in a visualized house. Some were practical, others intuitive, and others tough as nails. She would visualize the pathway to the different alters’ rooms to access them; whoever had the best skills then emerged to deal with whatever life dished out. Except for now, when some of them had mysteriously gone missing. I sincerely told Natalie—an extremely intuitive woman, or collection of women—that I thought she had a “wonderful system,” and suggested she think of all the ways she had gained access to her alters before.

A possible source to the problem was finally discovered. Natalie said she thought that the alters were hiding because her boyfriend, Joe, was embroiled in extreme, ongoing arguments with a brother and sister over the impending sale of their grandparents’ farm. Natalie believed that the alters were frightened and hiding much like they did when she was a child. Once Joe became less unpredictably volatile, Natalie thought, access to her missing alters would return. With this discovery made, we focused on ways to address Joe’s anger, and otherwise, in Natalie’s words, “deflect it” and diminish its impact on her alters. Natalie implemented our ideas and Joe responded by calming down and becoming more attentive to Natalie’s needs. Subsequently, over the next days, several others “came home.”

But my confusion didn’t stop there. With the crisis with Joe abated, Natalie identified a new goal of addressing her Epstein-Barr virus. In the next session, a wise, spiritually centered, martial artist alter named “Nora” showed up. Since Natalie was already adept at visualization, I had planned to suggest that we fine tune her skills to rally her resources against the virus. I suggested this to Nora instead and we worked on various martial arts images to combat the virus. I wondered aloud if it was possible to teach the others the same skills and Nora said she would try.

Perhaps in my most speechless encounter with a client, Natalie appeared in the next session and with great enthusiasm exclaimed, “I’m a me! My experienced and tempered empathic therapeutic response: “Say what?” This video sequence has brought down the house in my trainings. I am so dumbfounded, so confused—I clearly don’t know what the hell is going on. But as I always say, at least I was authentically stupid!

Then Natalie explained: Nora had called a meeting in a visualized library to communicate to the alters what she had learned about Epstein Barr. It was the first time they had all been in the same room together. Natalie reported that each alter had come forward, naming her special gifts to the overall system. After praying together, each alter had said, “I belong.”

Then Natalie told me, “Now I’m a ‘me,’ and I’m different. I am the collage of their gifts. Everybody’s there. And if they want, they could still come out, but I’m a me. This me is finding out a lot of things. I’m articulate. I have movement. I definitely have a temper, and I can express it. It’s like I’m looking through a pair of new eyes that have never been touched or scarred.” Again, I was dumbstruck! She had gone beyond “co-consciousness” to a form of integration that she welcomed. I sat stunned for some time before Natalie asked me if she could give me a hug. I am not sure, in retrospect, whether it was celebratory hug or one designed to comfort me and reel my confusion in.

Natalie stands out to me because I never have felt more cast adrift. I didn’t have a clue about what to do—no theoretical or technical training prepared me for this client and how therapy progressed over time. In reality, that’s the way it always is. But I was there hunting for what could work, adding something when I could—the anger suggestions and the imagery to help combat the virus—until the unexpected occurred. I believe it is best described, for me, as a collaborative expedition for the magic of the moment. Not the magic of the sweeping, dramatic gesture or an isolated technique or any other novelty, but rather the magic that grows out of exploring the client’s world, validating their experiences, and discovering what works.

2) Have you ever had to make use of a method, technique or a theory in a therapy session, where you have found it necessary to compromise your ethics or values in life, to create or retain a good alliance and effectiveness in therapy?
No. I have experienced many encounters with clients in which I challenged my values and ethics, and perhaps stretched them, but not compromised them. Here is one example. This is a bit of tawdry tale. Richard, a 29-year-old systems analyst, was referred by his company doctor because of Richard’s increasing distress and frequent absences. When I greeted Richard in the waiting room, he jumped out of his chair, got right in my face—not 3 inches away—and demanded “What are you going to do for me?”

Richard didn’t look too good. The 60 cent therapy words would be agitated and disheveled. I tried to stay calm and just invited him to accompany me to my office, whereupon Richard raised his voice another notch and repeated his question, and was once again, too close for comfort.

I was definitely freaked at this point but I simply replied that I didn’t know if I could do anything for him but that I would try my very best. Richard finally sat down on my couch and told his story, and the flood gates opened. Richard began suspecting his wife, Justine, of having an affair after he discovered footprints in the snow in his backyard. Consequently, he followed her, searched her belongings, and kept track of her whereabouts. But he could not find the incontrovertible evidence that he was sure existed. Throughout Richard’s growing mistrust, Justine emphatically denied the affair and told him he needed help. Perhaps in desperation, Richard began to secretly check Justine’s underwear for signs of semen, which would provide ironclad evidence of her unfaithfulness (given there was no sex with him).

Finally, Richard found stains on her underwear and took it to a laboratory which confirmed the presence of semen. Justine still denied his accusations and insisted the semen was his. She stepped up her efforts to involve others, telling friends, family, his employer, and their own children, that Richard was sick and in need of hospitalization. Justine rallied many to her cause and filed for divorce. The company doctor concurred with her assessment, as did the first provider that Richard saw, a psychiatrist who offered an antipsychotic to ease Richard’s pain.

After Richard’s first unsuccessful encounter with the psychiatrist, the company doctor was peeved. Perhaps hoping to admonish Richard into sanity, he had yelled “Cut the crap!” Richard didn’t do much to disconfirm everyone’s assessment of his sanity. He was doing some pretty whacky things, and looked more distressed and haggard with each passing day.

Richard told me that he was obtaining a DNA analysis of the semen to see if it was a match with his. While scrutinizing my every reaction, not in a threatening way but rather like a condemned man waiting for a sentence, he nervously asked me if I believed him.

So was Richard psychotic or was Justine a liar? Subsequently, I talked with Justine and invited her to therapy but she declined. She was very persuasive and pulled out all the stops to describe Richard as a hopelessly psychotic and in need of medical help, noting that Richard’s sister was also schizophrenic and lived in a group home. What would you say to Richard?

I told Richard that I did believe him. Richard allowed himself a moment of relief, but pressed on and told me that the DNA test was going to cost a lot of money. He then leaned forward, stared uncomfortably, and asked me the big question: did I think he was crazy for spending all that money?

I responded that peace of mind is cheap at any price. Richard broke down and cried long and hard. He had been through a lot, and was starting to believe what many had told him—that he was paranoid and needed medication. After a while, we started talking about what he needed to do to stop looking crazy while he waited on the DNA results. If we took the affair as a given, and that her intent was to make him look crazy as a loon, then everything he was doing was playing right into her hands. Richard and I worked out a plan to get normalcy back in his life: return to work, start spending time with his kids, and taking better care of himself. He did all of those things and continued to bide his time as best he could.

Finally the results came in. Although Richard was greatly saddened when the DNA results confirmed that the semen was not his, he was not surprised. Ultimately, the whole seamy business came to light, and Richard went about rebuilding his life.

I was so moved by Richard’s response, the depth of his wailing, to my simple act of believing him and understanding his desire to know what was going on that I have never forgotten it. Richard taught me that I have to believe my clients, pure and simple. Honestly, while Richard told me his story, I struggled with believing him, which I knew was risky to our alliance. But I ultimately made a conscious choice, during that session, to believe Richard—that it didn’t matter how bizarre it seemed or how classically paranoid it looked. I decided, at the very least, that my clients deserve to be believed. That was a significant event in my development as a therapist. From that day on, I no longer struggled with being a reality police officer And while it’s true that sometimes people do lie, even maliciously, like Justine, I am willing to suspend disbelief until the “facts” appear or maybe into perpetuity.

3) What is the most fun part of working with clients within a frame of reference which contains no fixed techniques, theory or method?

The most fun part is never knowing what is going to happen when you put two resourceful, unique individuals in a room who engage each another in this beautiful interpersonal event we call psychotherapy. The magnificently inexplicable is always lingering, and the joy of discovery ever present. The uncertainty within a frame of reference with no fixed ideas ore methods creates unlimited possibilities for change. It is this indeterminacy that gives therapy its texture and infuses it with the excitement of discovery. This allows for the “heretofore unsaid,” the “aha moments,” and all the spontaneous ideas, connections, conclusions, plans, insights, resolves, and new identities that emerge when you put two people together and call it therapy. This doesn’t mean, of course, that it’s all fireworks (just watch an entire session rather than edited video clips), it just means that tolerance for uncertainty creates the space for new directions and insights to occur to both the client and the therapist.

The tolerance for uncertainty, however, requires faith—faith in the client, faith in yourself, and faith in psychotherapy. But I am certain of one thing: uncertainty is the key that unlocks the potential for discovery. It is hard to discover something if you already know what it is that you are looking for and where it is. Because CDOI is unencumbered by any particular theoretical or explanatory concepts, there is a freedom to speculate. Some ideas grow into relevant discussion, while others fade away as it becomes apparent they are not helpful to pursue. This process seeks to chart a different course—connections, conclusions, solutions, etc.—in any form, that permits a way to address the client’s goals, to encourage an increase on the Outcome Rating Scale (available in Danish, free for personal use at www.heartandsoulofchange.com).

From a discovery-oriented perspective, the word “intervention” does not adequately describe the collaborative process that emerges. To intervene is “to come into or between by way of hindrance or modification.” It implies something done to clients rather than with them, and consequently overemphasizes the technical expertise of the therapist, inaccurately portraying what makes therapy successful. The word intervention does not capture the interdependence of technique on the client’s resources and ideas or how technique is successful to the extent that it emerges from the client’s positive evaluation of the alliance. The words “invent” and “invention” seems more apropos to discovery. To invent is to “find or discover, to produce for the first time through imagination or ingenious thinking and experiment.” Every technique is used for the first time, invented by clients and therapists to fit the client’s unique attributes and circumstance.

The therapist and client are co-explorers, searching the client’s world for the map that provides a route of restoration. As co-adventurers, you encounter multiple opportunities for sharing your respective vantage points while crossing the terrain of the client’s world, periodically stopping to consult your ORS/SRS compass to ensure you are headed in the right direction. When lost along the way, you regroup to look for alternate routes on your maps, as well as the maps of others you encounter on the journey. Such expeditions often uncover trails that we never dreamed existed.

4. If you at one point in your life was to seek therapy (of course depending on why) how would I as a therapist manage to obtain a good alliance between us and ensure effectiveness?

I have consulted a therapist twice in my life and I had a good experience both times. I don’t think I would want anything different than most clients who make their way into our offices. I want to be heard, understood, and respected. I want you to see me as transcending my problems, that my humanity is not represented by the problem, that I am not my problem. I want validation of my experience and for you to believe that I have good reason to think, feel, and behave the way I do, even if it doesn’t fit your experience. Finally, I would want my ideas about how I might change to remain central, and that your interest in your own ideas would fade if they did not resonate with me.

The best way to secure a good alliance with me and ensure effectiveness would be to monitor both the alliance and outcome in each session. This would not leave either the alliance or effectiveness to chance. By creating a culture of feedback, and aspiring to transparency and collaboration, together we could make sure that we were on the right track regarding my benefit from your services and that you were fitting my expectations about how therapy was conducted. If things were not going well, your non-defensive response would be critical along with your wiliness to explore options, including referring me on to someone else.

And don’t forget this month’s free webinar about my book, 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  I’ll start our discussion with a 25 minute overview and then I’ll turn it over to you for your questions, comments, and reflections. It should be fun. For those of you who can’t attend live, I’ll record the sessions and post them on the website so you can access the discussions at your leisure.

Clients are indeed the best teachers. The following client, Peter, taught me about the importance of soliciting client ideas about what might be helpful or what I later called “the client’s theory of change.” This is an excerpt from On Becoming a Better Therapist:

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

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

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

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

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

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

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

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

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

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

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

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

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

Here is an excerpt from On Becoming a Better Therapist:

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

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

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

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

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

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

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

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

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

I am excited to announce a seven month series starting in July of webinars and discussions about my new book, On Becoming a Better Therapist.  First here is a brief review of the book:

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

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

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

Here is the free webinar announcement:

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

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

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

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

Hope you join me!

I am very pleased to announce that our alliance article from the Norway Feedback Project (Anker, Owen, Duncan, & Sparks, in press) was accepted in the prestigious Journal of Consulting and Clinical Psychology (JCCP). Congrats to the whole team: Morten Anker, Certified Trainer, Jesse Owen, Research Director, and Jacqueline Sparks, Project Leader. Although already well established in terms of its widespread use and validated psychometrics, this is a major step forward for the Session Rating Scale (our alliance measure), bringing it more academic credibility, and importantly, it allows mainstream scientific dissemination of the idea of continuous alliance monitoring. The Outcome Rating Scale/Session Rating Scale combo (or the Partners for Change Outcome Management System or PCOMS), btw, is the only outcome system that includes routine alliance monitoring. And the SRS is the only alliance measure specifically designed for the front line clinician for use with every client in every session.

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

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

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

Finally, the next webinar is scheduled:

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

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

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

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

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

My new book, On Becoming a Better Therapist, is out, and I am excited to tell you a bit about it. Here is the marketing blurb:

Most of us became therapists because we wanted to be helpful to other human beings, and most of us carry an inextinguishable passion to become better at it. But how do we get better? Do we rest on our laurels hoping that the platitudes about clinical experience will finally pay dividends? Or do we continue searching for the Holy Grail—the “right” approach—even though our experience tells us that even the most empirically supported models “work” perfectly for one client, but do nothing for another. The truth is that although we are painfully aware that some clients clearly don’t benefit while others inexplicably end therapy, we don’t know how effective we really are or what we can do to improve our outcomes. Despite our hard work and good intentions, unfruitful encounters with clients combined with the confusing cacophony of “latest” developments can weigh on us, steer us into ruts, and make us forget why we became therapists to begin with. How can we remember our original aspirations, continue to develop as therapists, and achieve better results, more often, with a wider variety of clients? In short: how can you become a better therapist?

On Becoming a Better Therapist answers these questions and more. Barry Duncan pragmatically applies the common factors of change as well as the powerful benefits of client feedback described in the The Heart and Soul of Change to demonstrate how to be even better at what you do best and, at the same time, expand your effectiveness with clients who may not respond to your usual efforts.

In the first book to detail the clinical nuances of using feedback to improve outcomes, Duncan presents a simple, five-step method of integrating outcome management with therapists’ long-term professional development. With lively case examples, unfailing good humor, and a deep affection for therapy and therapists, Duncan’s book is essential reading for anyone who seeks to rediscover purpose in their work and become a better therapist.

 Feedback pioneer Michael Lambert says, “The possibility and novelty of Duncan’s ideas makes this an important and provocative contribution to the field.”In this book I suggest that you step up to the plate with two things: attaining systematic client feedback and taking your development as a therapist to heart. Integrating these two critical aspects, I believe, can open new vistas for therapists wishing to rapidly impact the quality of their work with clients. Order it here.

I also want to invite you to check out the Heroicagency listserv–a community of over 800 mental health and substance abuse professionals from all over the world who provide a 24/7 resource for all those interested in the ideas and practices promoted on this website. Join now and connect to a network of people striving to privilege clients in the delivery of services while forming true partnerships to monitor outcome and the alliance. Among many free supportive and educational functions of the list, a new feature begining this summer will be guided discussions based on Heart and Soul of Change Project readings. I will kick off this new feature with my new book. 

And I am pleased to announce that Dr. Jesse Owen has joined the Project as our Research Director. Jesse will oversee the HSCP Research Award and is a key player in several current research projects addressing CDOI ideas and practices. Welcome aboard Jesse!

Finally, be sure to register soon for the Heart and Soul of Change Conference in New Orleans to take advantage of the early registration discount.

I just did a brief video (see below) for the Louisiana Counseling Association’s Annual Conference to invite folks to the Heart and Soul of Change Conference occurring June 17-19 in perhaps the most exciting city in North American, New Orleans. http://heartandsoulofchange.com/training/heart-and-soul-of-change-conference/  That reminded me to blog more about the details.

Heart and Soul of Change, New Orleans

The conference will be just a stone’s throw away from the French Quarter at the InterContinental Hotel http://www.ichotelsgroup.com/intercontinental/en/gb/locations/neworleans and I am very happy to say that the room rate was negotiated to be a very reasonable $119 per night. Check out the video tour of the hotel and what New Orleans has to offer. We want you to get the most out of your visit, not only with regard to the quality of the presenters and the stellar training opportunity this conference offers, but also your experience of this spectacular city. Consequently, lunch breaks will be a full two hours so that you can explore the amazing culinary experiences awaiting you in the French Quarter. New Orleans is such an historical, festive, musical, culinary, cultural place that you have to experience firsthand to appreciate it.

Another reason this conference is exciting for me is that I will be presenting my five steps to accelerate your development as a therapist that I detail in my new book, On Becoming a Better Therapist due out in March. Here is a brief description. The five steps build on the lessons I’ve learned from incorporating feedback in my work and helping others do it, but also integrates research about therapist development. A pre-requisite is your understanding that you are a primary figure in each client’s ultimate outcome—the client is certainly central, but as the old saying goes, it takes two to tango. Your view of your growth impacts your ability to be vitally involved in the therapeutic process. Collecting outcome feedback begins the process. The first step is to track your cumulative career development and take it on as a project. Proactively monitor your effectiveness in service of implementing strategies to improve your outcomes. Practice the skills of your craft and monitor your results.

Next, deliberately expand your theoretical repertoire and loosen your grip on the inherent truth value of any given approach. Take multiple vantage points on your journeys with clients while you search out different understandings of client dilemmas. Plurality of perspective serves you and your clients. Theoretical breadth enriches the therapeutic process while simultaneously increasing your involvement in and satisfaction with the work. Third and most importantly, pay close attention to your currently experienced growth. Take a step back, review your current clients and consider the lessons you are learning. Empower yourself, like you would your clients, to enable the lessons to take hold and add meaning to your development as a therapist. Articulate how client lessons have changed you and your work, and what it means to both your identity as a helper and how you describe what it is that you do.

Fourth, continuing that theme, reflect about your identity and construct a story of your work that captures what you do as a helper. Continue to edit and refine your identity and accounts of what constitutes the essence of your work—evolve a description that you can have allegiance to but that doesn’t lead to dead ends. Finally, accumulate the gems of your experiences with clients and the gifts of their feedback, and secure them safely in your Treasure Chest. The Treasure Chest is the place to go to escape tough times and reconnect to the work, to why you become a therapist in the first place. It is also the place to record, through your clients and your own narrative accounts, your development as a therapist. To learn more about the five steps, subscribe to CDOIMembers at http://heartandsoulofchange.com/training/cdoi-members/

Bottom Line: If you got into this business, like me and the majority of therapists I meet, because you wanted to help people, you already have what it takes to become a better therapist. It boils down to two things: One is your commitment to forming partnership with clients to monitor the alliance you have with them and the outcome of the services you are providing. The second is your investment in yourself, your own growth and development. Systematic client feedback provides the method for both.

It is always fun to post good news, to let folks know that CDOI continues to grow and is having an impact. One area that will lead to the expansion of CDOI practices is its inclusion in graduate training programs. This is a major strategic goal of the Heart and Soul of Change Project (HSCP) and we will reach out to professors and researchers to invite them to both conduct research and teach CDOI ideas and practices. The Norway Feedback Project will assist us in this endeavor because it brings academic credibility to the measures and is a nice calling card.

You might already know that Dr. Jacqueline Sparks, Project Leader at the HSCP, has implemented an outcome management protocol with students in her MFT program and clinic at the University of Rhode Island. Jackie’s program uses ASIST and can truly claim to not only train competent clinicians, but also effective ones. It also sets the course for new graduates on a lifelong journey of monitoring their effectiveness and their cumulative career development. Consider the benefits for these budding clinicians and for anyone who decides to monitor outcomes over the course of their career. Such a process allows a strategic trial and error application of new learning as well as the continual refinement of the tried and true mechanisms that we know enhance outcomes. In short, it enables you to take action about your effectiveness. It permits you to learn from your experience, not repeat it. (see below)

Now Jackie’s program is not the only one.

Jeff Reese, the researcher at University of Kentucky who conducted an independent RCT using the ORS and SRS that will soon appear in the prestigious journal Psychotherapy, brought me to UK last week to present to both students and faculty, and the community. After my visit with the Counseling Psychology department, standing on the strong shoulders of Jeff’s work, the program faculty unanimously decided to implement the ORS and SRS as an integral piece of their clinical training. Students will use the measures in their practicum training, and the faculty believes that it will not only strengthen their training, but will also operationalize their commitment to social justice. That’s what I am talking about!

The Heart and Soul of Change Project, like my new book, On Becoming A Better Therapist, suggests that you step up to the plate with two things: attaining systematic client feedback and taking your development as a therapist to heart. Integrating these two critical aspects, I believe, can open new vistas for therapists wishing to rapidly impact the quality of their work with clients. Attaining client feedback is a simple but clinically nuanced process of collaborating with clients, forming true partnerships, and enhancing the factors known to impact outcomes. It helps us know we are on track, enables us to empower change, and it provides an early warning system for clients at risk for drop out or other negative outcomes. Collecting client feedback also paves the way for your development as a therapist.

In a remarkable study, veteran researchers David Orlinsky and Helge Rønnestad (2005) took an in-depth look at therapists’ experience of their work and professional growth. Over a 15 year period, they collected richly detailed reports from nearly 5000 psychotherapists of all career levels, professions, and theoretical orientations from over a dozen countries. From their analyses of many specific aspects of therapeutic work, a mode of therapist participation was identified:

Healing Involvement reflects a mode of participation in which therapists experience themselves as personally committed and affirming to clients, engaging at a high level of basic empathic and communication skills, conscious of Flow-type feelings during sessions, having a sense of efficacy in general, and dealing constructively with difficulties if problems in treatment arose. Healing Involvement represents us at our best—the way we want to be with our clients. Think of it as being “in the zone” akin to how athletes describe their experience when their performance is optimal. Their extensive investigation identified three sources of Healing Involvement, a therapist’s experience of being in the zone: First is the therapist’s sense of cumulative career development—improvement in clinical skills, increasing mastery, and gradual surpassing of past limitations. Second, another important influence on Healing Involvement is the therapist’s sense of theoretical breadth. Orlinsky and Rønnestad suggest that understanding clients from a variety of conceptual contexts enhances therapist’s adaptive flexibility in responding to the challenges of clinical work. Indeed, broad spectrum integrative-eclectic practitioners were more likely to experience Healing Involvement. The third and by far most powerful influence on being in the zone is the therapist’s sense of currently experienced growth. Therapists like to think of themselves as developing now. Your ongoing experience of professional development is therefore critical to becoming a better therapist. In a sense we continually ask ourselves, “What have you done for me lately?” Therapists with the highest levels of current growth showed the highest levels of Healing Involvement. Orlinsky and Rønnestad suggest that the experience of current growth translates to positive work morale and energizes therapists to apply their skills on behalf of clients.

How does all this relate to client feedback? Tracking client responses to therapy provides an accessible route to being in the zone, addressing all three sources identified by Orlinsky and Rønnestad. First, collection of client feedback allows you to monitor your outcomes and plot your career development, so you will know about your effectiveness and whether you are improving. Moreover, charting your outcomes not only permits a more systematic process of planning and implementing strategies to improve your effectiveness, it also permits your evaluation of the strategies and whether or not your time might be better spent elsewhere. Second, tailoring your approach based on client feedback about benefit and the fit of the services will lead you to theoretical breadth as you expand your repertoire to serve more clients. Soliciting client feedback enhances your ability to be tuned to client preferences and encourages your flexibility to try out new ideas in search of what resonates with clients—opening you to a range of theoretical explanations and attending methods. Finally, securing client feedback seats you in the front of the class so you can readily see and hear the lessons of the day—to experience your currently experienced growth. Practice based evidence encourages your continual professional reflection with each client, thereby increasing your learning potential exponentially. Client feedback is the compass that provides direction out of the wilderness of negative outcomes and average therapy—taking the notion of clients as the best teachers of psychotherapy well beyond cliché, significantly accelerating your development as a therapist, and helping you become a better one.

Over the next several months, I’ll blog how you can accelerate your development as a therapist. Stay tuned.